Healthcare DOE Sup

HEALTHCARE DOE SUP

This Healthcare DOE Sup is a supplemental authorization and information form for the disclosure, update, or supplementation of protected health information and related educational/administrative records. Completion of this form authorizes the release and use of the information described below for the stated purpose. Patient Name: Date of Birth:

Patient Information

Insurance Information

Medical History / Current Status

Supplemental Records Requested

Date(s) of service being supplemented:

Records attached: Medical Educational/School Other

Authorization to Disclose / Receive

I hereby authorize the release and exchange of the supplemental information described above between the provider(s) and the recipient named below. This authorization includes disclosure to and from educational or administrative entities when necessary to coordinate care, accommodations, or services.

Sensitive information: I specifically authorize release of the following categories only if indicated below (initial and check applicable boxes):

HIV-related information Mental health records (psychotherapy notes excluded unless specifically listed) Substance use treatment records

Duration, Revocation, and Redisclosure

This authorization is effective immediately upon my signature and will expire on: . I understand I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it. To revoke, submit written notice to the releasing provider. This authorization does not affect the ability of the provider to continue treatment that would otherwise be provided if I do not sign.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by applicable privacy laws, except where protections are provided by law for certain records. Where state or federal law requires additional protections, the recipient must comply with those protections.

Fees and Charges

I understand that reasonable fees for copying and administrative processing may be charged in accordance with the releasing provider's policies and applicable law. If fees apply, I will be notified and billed prior to release unless otherwise permitted by law.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have been informed of my privacy rights under health information privacy law and that I authorize the uses and disclosures described in this form. I understand I may request a copy of this authorization for my records.

I acknowledge that I have received or been offered a copy of the privacy practices applicable to my care.

Certification

I certify that I am the patient or authorized representative of the patient and that the information I have provided is true and complete to the best of my knowledge. If signing as a representative, I certify I have the authority to act on behalf of the patient and, if requested, will provide documentation of such authority.

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