Healthcare PHI Questionnaire

Healthcare PHI Questionnaire

Use this form to identify the specific categories of Protected Health Information (PHI) to be reviewed, released, or discussed. Completion of this questionnaire assists the health care provider in complying with applicable privacy and authorization requirements. Complete all applicable sections and sign at the end to authorize disclosure.

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Insurance Information

Group Number:    Subscriber Name:

Medical History (Brief)

Protected Health Information to Be Disclosed

Select all categories of PHI that apply:

Medical records and clinic notes
Laboratory reports and diagnostic testing
Imaging reports (X‑ray, CT, MRI)
Immunization records
Billing, claims, and financial records
Mental health / psychotherapy notes (explicit authorization required)
Substance abuse treatment records (explicit authorization required)
HIV/AIDS testing and related records (explicit authorization required)
Genetic testing/results (explicit authorization required)
Other (describe below)

Purpose of Disclosure

Continuity of care / treatment coordination
Billing / insurance claims
Insurance review / underwriting
Legal / court proceedings
Personal use by patient
Research (limited; requires separate approvals)
Other (describe below)

Time Period and Expiration

Disclosure covers PHI for the period from through    All past, present and future records

If no expiration date or event is specified, this authorization will expire one year from the date signed, unless otherwise prohibited by law.

Sensitive PHI — Explicit Authorization

For release of the following categories, the patient or authorized representative must expressly initial to authorize disclosure.

HIV/AIDS Records:    Substance Abuse Treatment Records:

Mental Health / Psychotherapy Notes:    Genetic Testing/Results:

Authorization and Patient Rights

By signing below, I authorize the health care provider and its workforce to use and disclose my Protected Health Information as described in this questionnaire. I understand that: (a) I may revoke this authorization at any time by providing a written notice of revocation to the health information management or privacy officer, except to the extent that action has already been taken in reliance on this authorization; (b) treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this authorization except where permitted by law; (c) information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations; and (d) I may inspect and copy the PHI described in this authorization by submitting a written request.

I understand that I may revoke this authorization at any time by submitting a written revocation to the provider's Privacy Officer. Revocation will not affect disclosures made prior to receipt of the revocation. I understand that certain types of records (for example, records compiled in reasonable anticipation of litigation) may be subject to special limitations on use or disclosure.

I acknowledge that I have been provided with the facility's Notice of Privacy Practices and that I understand my rights with respect to my PHI.

I acknowledge receipt of the Notice of Privacy Practices and understand my rights as described above.

Additional Instructions / Special Handling

Patient Certification

I certify that I am the individual whose PHI is the subject of this authorization, or I am the individual's authorized representative and have legal authority to execute this authorization on behalf of the individual. If signing as an authorized representative, I must provide proof of authority upon request.

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