Healthcare ISA Letter

HEALTHCARE ISA LETTER

This Healthcare ISA Letter (Information Sharing Authorization) authorizes the disclosure of the patient’s protected health information as described below. Patient Name: Date of Birth: Gender:

Patient Information

Recipient / Authorized Parties

I authorize the following person(s) and/or entity(ies) to receive or disclose my protected health information (check all that apply and complete contact information):

Purpose of Disclosure

Purpose(s) for which disclosure is authorized (select or describe): Insurance claim / benefits administration, continuity of care, legal representation, personal use, other. Purpose description:

Information to Be Disclosed

I specifically authorize disclosure of the following categories of health information (check all that apply). Sensitive categories require specific authorization where applicable.

Medical records, history and progress notes
Laboratory and pathology results
Imaging reports (X-ray, MRI, CT)
Mental health and psychotherapy notes (sensitive)
Substance use disorder treatment records (sensitive)
HIV/AIDS-related information (sensitive)
Billing, insurance and payment records
Other (specify below)

Insurance Information

Medical History (Relevant)

Expiration, Revocation, and Redisclosure

This authorization will expire on: If no date or event is provided, this authorization will expire one year from the date signed unless otherwise required by applicable law.

I understand that 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, provide a written notice to the disclosing entity identified above.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. Redisclosure is prohibited for certain sensitive records unless specifically authorized by law.

Authorization and Certification

By signing below I certify that I am the patient or am authorized to act on the patient’s behalf. I authorize the use and disclosure of the specified protected health information as described in this document. This authorization is voluntary and I have the right to refuse to sign. I acknowledge that refusal to sign will not affect my ability to obtain treatment, payment, enrollment, or eligibility for benefits unless allowed by law.

I understand that certain categories of information (for example, psychotherapy notes, substance use treatment records, and HIV-related information) require explicit authorization and will only be disclosed if those categories are specifically checked above.

If this authorization is signed by a personal representative on behalf of the patient, complete the relationship and authority description below.

Acknowledgment of Privacy Practices

I acknowledge that I have been informed of my privacy rights and the entity’s privacy practices regarding protected health information, and that I have the right to receive a copy of this signed Authorization upon request.

Initials:

Emergency Contact

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