Healthcare HPIPA Designation Form

HEALTHCARE HPIPA DESIGNATION FORM

This Healthcare HPIPA Designation Form authorizes the release, inspection, and copying of protected health information in accordance with the Health Privacy and Information Protection Act (HPIPA) and applicable privacy rules. The patient named below hereby designates one or more personal representatives to receive the specified health information and to act on the patient's behalf as set forth in this authorization.

Patient Information

Patient Name:

Insurance Information

Medical History Summary

Designation of Personal Representative(s)

I hereby designate the following individual(s) as my personal representative(s) for purposes of access to my protected health information and for making health care decisions to the extent permitted by law.

Scope of Access — Check all that apply

Medical records, including history, diagnoses, treatment notes and test results

Billing, claims, and payment information related to care

Mental health records (including psychotherapy notes only if specifically authorized)

Substance use disorder treatment records (if applicable)

Genetic testing results and related genetic information

Other (specify):

Purpose of Designation

The personal representative is authorized to receive and inspect records for the following purpose(s). Check all that apply:

Continuity of care and coordination of treatment

Billing, payment and insurance matters

Legal representation or disability/benefit claims

Personal management of health information and decision-making

Other (specify):

Duration and Expiration

This designation is effective as of: and expires on: .

If no expiration date is provided, this designation will remain in effect until revoked in writing by the patient or the patient's authorized representative.

This designation remains in effect until revoked in writing.

Revocation and Limitations

The patient may revoke this designation at any time by providing a written notice of revocation to the health care provider or facility holding the records. Revocation will not affect actions taken in reliance on this designation prior to receipt of written revocation, nor will it affect disclosures made in response to this designation while it was in effect.

This designation does not authorize disclosure of information prohibited by applicable law unless the patient has provided separate written authorization for those specific categories of information.

Redisclosure

The recipient of the protected health information may be subject to redisclosure and the information may no longer be protected by HPIPA or other privacy provisions. The health care provider is not responsible for any subsequent redisclosure by the designated representative.

Acknowledgment of Privacy Practices

By signing below, I acknowledge that I have been offered or received a copy of the provider's privacy notice describing how my health information may be used and disclosed, and I understand the rights and limits described in that notice.

I acknowledge receipt of the privacy notice.

Certification

I certify that I am the patient named herein or that I am the lawful guardian, legal representative, or have the necessary authority to execute this designation on behalf of the patient. I understand that falsifying information on this form may subject me to civil or criminal penalties under applicable law.

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