Healthcare Extraction Process

HEALTHCARE EXTRACTION PROCESS

This Healthcare Extraction Process ("Process") documents the authorization, scope, methods, responsibilities, and legal assurances governing the extraction, transfer, and use of protected health information and/or biological specimens for the purpose(s) stated below. Facility/Provider:

Patient Information

Patient Name:    Date of Birth:

Insurance Information

Extraction Details

Purpose of Extraction (check all that apply):

Types of information or specimens to be extracted (check all that apply):

Legal Terms, Risks, and Acknowledgments

Authorization: I authorize the Facility/Provider named above to extract the specified protected health information and/or biological specimens and to disclose such information and/or specimens to the Recipient(s) named above for the purposes indicated. This authorization includes the extraction of records that may contain sensitive information, including but not limited to mental health, substance use treatment, HIV-related information, and genetic test results, unless I have specifically excluded such categories below.

Risks and Protections: I acknowledge that extraction and transfer of health information and specimens involve risks, including inadvertent disclosure, interception during transfer, and use by recipients beyond the purpose stated. The Facility/Provider will employ reasonable technical and administrative safeguards for secure transfer. The Facility/Provider is not responsible for subsequent disclosures by the Recipient(s). I understand that I may request additional contractual protections from Recipient(s) and that such protections are outside the scope of this authorization unless expressly documented below.

Redisclosure and Use: I understand that once the information or specimens are disclosed to the Recipient(s), federal privacy rules may not protect the information from further redisclosure by the Recipient(s). The Recipient(s) may use the information only for the purposes stated above unless further authorization is obtained.

Right to Revoke: I understand that I may revoke this authorization at any time by submitting a written revocation to the Facility/Provider, but the revocation will not affect disclosures made in reliance on this authorization prior to receipt of the revocation. Revocation must be sent to Facility/Provider at the address on file and must specifically identify this authorization.

Fees: I understand that the Facility/Provider may charge a reasonable fee for copying and transferring records or specimens, consistent with applicable law. I will be responsible for any pre-authorized charges unless otherwise agreed in writing.

Patient Medical History Summary (for extraction planning)

Authorizations and Certifications

By signing below, I certify that I am the patient or am authorized to act on behalf of the patient as the patient's legal guardian or personal representative. I authorize the extraction and disclosure described in this Process. I have read and understand this document, including the risks, expiration, and revocation provisions. I acknowledge that signing is voluntary and that my treatment or eligibility for benefits will not be conditioned on signing this authorization except where permitted by law.

Witness (optional): Witness Printed Name:    Signature:    Date:

Record of Extraction Completion (to be completed by Facility/Provider): Date completed:    Method used:

Facility Representative Name:    Signature:    Date:

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