Healthcare DICOM Agreement

HEALTHCARE DICOM AGREEMENT

Patient Name:   Date of Birth:   Medical Record Number:

PARTIES AND PURPOSE

Sender / Custodian of Records (Facility Name):

Recipient / Requesting Party (Name or Organization):

Purpose of Disclosure: Treatment / Continuity of Care   Personal Use   Legal / Litigation   Research (separate IRB/consent may be required)

DEFINITIONS

For purposes of this Agreement, "DICOM Data" means medical image data and associated metadata stored or transmitted in the Digital Imaging and Communications in Medicine (DICOM) format. "Protected Health Information" or "PHI" has the meaning provided under applicable privacy laws and includes any DICOM header fields or other data that can reasonably be used to identify the patient.

SCOPE OF RECORDS TO BE TRANSMITTED

Select modality types and provide timeframe for the requested DICOM studies:

CT   MRI   X-ray   Ultrasound   PET   Other:

Date range of studies: From to .

FORMAT, TRANSMISSION, AND SECURITY

Format requested: Native DICOM (with header metadata)   Embedded JPEG/JPEG2000   Other:

Transmission method: Secure DICOM Send / PACS Transfer   Encrypted Portal Transfer   Physical Media (CD / USB)   Other:

If physical media, handling instructions:

DE-IDENTIFICATION / PHI HANDLING

Release of PHI in DICOM header: Release full headers including patient identifiers   De-identified DICOM (remove direct identifiers per standard)   Limited dataset (retain limited indirect identifiers)

Patient acknowledgment: By signing this Agreement, the patient understands that once DICOM files are disclosed to the Recipient they may be subject to redisclosure and may no longer be protected by the Sender's policies.

AUTHORIZATION, REVOCATION, AND EXPIRATION

Authorization: I authorize the Sender to disclose the DICOM Data described herein to the Recipient for the purpose(s) stated above. This authorization is voluntary and is not a condition of treatment, payment, enrollment, or eligibility for benefits.

Right to revoke: This authorization may be revoked by submitting a written revocation to the Sender's records custodian. Revocation will not affect disclosures already made in reliance on this authorization prior to receipt of the revocation.

Expiration: Unless revoked earlier, this authorization will expire on: . If no date is provided, authorization will expire six months from the date of signature.

FEES, LIABILITY, AND INDEMNIFICATION

Fees: The Recipient or Patient may be charged reasonable reproduction and transmission fees in accordance with the Sender's policies. Charges must be disclosed in advance upon request.

Liability: The Sender will use commercially reasonable measures to transmit the DICOM Data securely. The Sender is not responsible for unauthorized access or disclosure that occurs after delivery to the Recipient or for the Recipient's handling of the data.

Indemnification: The Recipient agrees to indemnify and hold harmless the Sender and its agents from any claims, liabilities, losses, or expenses arising from the Recipient's misuse or unauthorized disclosure of the DICOM Data.

BREACH NOTIFICATION

In the event of an unauthorized acquisition, access, use, or disclosure of unencrypted DICOM Data constituting a breach, the party discovering the breach shall promptly notify the other party in writing and cooperate in any required mitigation and notification efforts, consistent with applicable law.

NOTICES AND CONTACTS

ADDITIONAL INSTRUCTIONS

CERTIFICATION AND ACKNOWLEDGMENT

I certify that I am the patient named above or the patient's legal representative with authority to sign on the patient's behalf. I have read and understand the terms of this Healthcare DICOM Agreement. I understand the purposes for which the DICOM Data will be used and the potential for redisclosure by the Recipient. I authorize the release of the DICOM Data as specified in this Agreement.

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