Change in PHI
lfhill
8 Posts
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In preparation for the changes in the law regarding PHI we have developed the following form to cover our bases and I thought it may be helpful to others and would like some input as to legality of such a form.
Authorization
For Protected Health Information Disclosure
In compliance with the addition of the PHI and Disclosure Rule to HIPPA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996) I /We the undersigned agree that by our signature below the Company, Health Care Provider, or its Authorized Representatives named below are authorized to release information under the Protected Health Information rule as follows:
• The Company, Health Care Provider or authorized representatives disclosing the PHI:
XYZ COMPANY 23 ANYWHERE STREET ANYWHERE USA 12345
• Person or Company to Receive or use the information: Check Applicable Box (s)
Health Insurance Company
Other insurance Company)
Life Insurance Company
Worhers Comp Insurance Company
XYZ Company
Other (Explain) _________________________________________________________________
The protected information will be used for the following Purpose:
New or amended application for Health / Dental Insurance.
New or amended application for Suplemental Insurance.
New or amended application for Voluntary Life Insurance.
Workmens Compensation Claims Filing and Handling.
Determination of Physical Qualification for Employment
Other (Explain) _________________________________________________________________
• This authorization can be revoked or recinded upon written request to the disclosing party.
• Information used or disclosed to the authorized party is subject to redisclosure.
• Information will be sent via regular First Class Mail unless the box below is checked authorizing us to send via facsimile transmission.
Permission to send PHI via facsimile transmission is authorized. I understand that information sent via facimillie transmission is not secure and agree to hold the company, Health Care Provider or authorized representitives blameless for any misdirection of information that may occur exposing protected information.
Unless otherwise revoked or recinded in writing to the disclosing party, this authorization will remain in full force and effect until __________________, 20________
_________________________________ ________________________
Signature Date
_________________________________ ________________________
Witness Date
*Please Note* PHI (Protected Health Information) is any individually identifiable health information transmitted or maintained in any form or medium (electronic or otherwise).
In preparation for the changes in the law regarding PHI we have developed the following form to cover our bases and I thought it may be helpful to others and would like some input as to legality of such a form.
Authorization
For Protected Health Information Disclosure
In compliance with the addition of the PHI and Disclosure Rule to HIPPA (HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996) I /We the undersigned agree that by our signature below the Company, Health Care Provider, or its Authorized Representatives named below are authorized to release information under the Protected Health Information rule as follows:
• The Company, Health Care Provider or authorized representatives disclosing the PHI:
XYZ COMPANY 23 ANYWHERE STREET ANYWHERE USA 12345
• Person or Company to Receive or use the information: Check Applicable Box (s)
Health Insurance Company
Other insurance Company)
Life Insurance Company
Worhers Comp Insurance Company
XYZ Company
Other (Explain) _________________________________________________________________
The protected information will be used for the following Purpose:
New or amended application for Health / Dental Insurance.
New or amended application for Suplemental Insurance.
New or amended application for Voluntary Life Insurance.
Workmens Compensation Claims Filing and Handling.
Determination of Physical Qualification for Employment
Other (Explain) _________________________________________________________________
• This authorization can be revoked or recinded upon written request to the disclosing party.
• Information used or disclosed to the authorized party is subject to redisclosure.
• Information will be sent via regular First Class Mail unless the box below is checked authorizing us to send via facsimile transmission.
Permission to send PHI via facsimile transmission is authorized. I understand that information sent via facimillie transmission is not secure and agree to hold the company, Health Care Provider or authorized representitives blameless for any misdirection of information that may occur exposing protected information.
Unless otherwise revoked or recinded in writing to the disclosing party, this authorization will remain in full force and effect until __________________, 20________
_________________________________ ________________________
Signature Date
_________________________________ ________________________
Witness Date
*Please Note* PHI (Protected Health Information) is any individually identifiable health information transmitted or maintained in any form or medium (electronic or otherwise).
