HIPAA Authorization Form

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

Direct Pay Virtual Clinic

SECTION 1: PATIENT IDENTIFICATION

Please complete all fields. This information is required to verify your identity before any records are released.

 

Patient Full Legal Name		Date of Birth
Current Address		Phone Number
City, State, ZIP		Email Address
Last 4 Digits of SSN (for identity verification only)		Patient ID / Chart # (if known)

 

SECTION 2: PERSON OR ORGANIZATION AUTHORIZED TO DISCLOSE INFORMATION

I authorize the following person or entity to DISCLOSE my protected health information:

 

Name of Person / Organization
Address
City, State, ZIP
Phone Number
Fax Number (if applicable)
Relationship to Patient

 

Note: In most cases, the disclosing party will be Direct Pay Virtual Clinic. If you are requesting records from a different provider to be sent to the Clinic, list that provider here.

SECTION 3: PERSON OR ORGANIZATION AUTHORIZED TO RECEIVE INFORMATION

I authorize the following person or entity to RECEIVE my protected health information:

 

Name of Person / Organization
Address
City, State, ZIP
Phone Number
Fax Number (if applicable)
Relationship to Patient

SECTION 4: DESCRIPTION OF INFORMATION TO BE DISCLOSED

4A. Type of Records Requested

Please check all that apply:

 

☐  Entire Medical Record (all records on file)	☐  Visit Notes / Progress Notes
☐  Laboratory Results	☐  Imaging / Radiology Reports
☐  Prescription / Medication Records	☐  Referral Documentation
☐  Billing / Financial Records	☐  Telehealth Visit Records
☐  Immunization Records	☐  After-Visit Summaries
☐  Other (please describe): _______________________________________________________________________________________________________________

 

4B. Sensitive Health Information

Minnesota law and HIPAA impose heightened restrictions on the following categories of sensitive health information. These records will NOT be included in any disclosure unless you specifically check the applicable box(es) below and authorize their release separately. Checking a box constitutes your specific written authorization for disclosure of that category.

 

☐  Mental Health / Psychiatric Records (Minn. Stat. § 144.294)	☐  Alcohol and Substance Use Disorder Treatment Records (42 C.F.R. Part 2)
☐  HIV/AIDS Test Results or Diagnosis (Minn. Stat. § 144.763)	☐  Genetic Information (GINA; Minn. Stat. Ch. 13)
☐  Sexual Assault Examination Records (Minn. Stat. § 145.1475)	☐  Reproductive / Pregnancy Health Records
☐  Other Sensitive Information (describe): _________________________________________

 

4C. Date Range of Records

 

From Date

To Date

☐ All Dates

SECTION 5: PURPOSE OF DISCLOSURE

I am authorizing this disclosure for the following purpose(s). Please check all that apply:

 

☐  Continuity of Care / Treatment by Another Provider	☐  Second Opinion
☐  Personal Records / Patient's Own Request	☐  Insurance or Benefits Claim
☐  Legal Proceedings / Attorney Request	☐  Disability or Workers' Compensation Claim
☐  School / Educational Institution	☐  Employment / Employer Request
☐  Research (IRB approval may be required)	☐  Life / Health Insurance Application
☐  Other (please specify): ____________________________________________________________________________________________________________________________

 

SECTION 6: EXPIRATION OF THIS AUTHORIZATION

This authorization will expire on the earliest of the following (please select one):

 

☐	Specific expiration date: ___ / ___ / _______
☐	Upon occurrence of the following event: ____________________________________________
☐	One (1) year from the date of my signature below
☐	90 days from the date of my signature below
☐	Upon completion of the specific purpose described in Section 5

 

If no expiration is selected, this authorization will expire one (1) year from the date of signature, consistent with Minn. Stat. § 144.293, Subd. 2.

SECTION 7: REQUIRED LEGAL DISCLOSURES

7.1 Voluntary Authorization

Your authorization is entirely voluntary. Direct Pay Virtual Clinic will not condition the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits on whether you sign this authorization, except in limited circumstances permitted by 45 C.F.R. § 164.508(b)(4). You have the right to refuse to sign this form without penalty.

7.2 Right to Revoke

You have the right to revoke this authorization at any time by submitting a written revocation to Direct Pay Virtual Clinic at info@directpayvirtualclinic.org or by mail to our business address. Your revocation will be effective upon our receipt of written notice. However, revocation will not apply to actions already taken in reliance on this authorization prior to receipt of your revocation. To revoke this authorization, please reference the date of this authorization and the name of the recipient in your written request.

7.3 Re-Disclosure Risk

Once your protected health information is disclosed to the recipient identified in Section 3, it may no longer be protected by HIPAA if the recipient is not a covered entity or business associate subject to HIPAA. Direct Pay Virtual Clinic cannot control how the recipient uses or further discloses your information after it has been released. We strongly encourage you to inquire about the recipient's privacy practices before authorizing disclosure.

7.4 Minnesota Health Records Act

This authorization is also governed by the Minnesota Health Records Act, Minn. Stat. § 144.293, which provides protections beyond federal HIPAA requirements. Under Minnesota law, this authorization must specifically identify the information to be disclosed, the recipient, the purpose, and the expiration. Authorization for disclosure of sensitive categories of information (mental health, substance use, HIV/AIDS, genetic information) requires separate, specific written authorization, which is captured in Section 4B of this form.

7.5 Sensitive Information Protections

The following categories of information are subject to heightened statutory protections and may not be disclosed without your specific written authorization in Section 4B above:

•       Mental health and psychiatric records: Minn. Stat. § 144.294; Minn. Stat. § 253B.03

•       Alcohol and substance use disorder treatment records: 42 C.F.R. Part 2 (Federal Confidentiality of Substance Use Disorder Patient Records); Minn. Stat. § 254A.09

•       HIV/AIDS test results and diagnoses: Minn. Stat. § 144.763

•       Genetic information: Genetic Information Nondiscrimination Act (GINA), Pub. L. 110-233; Minn. Stat. Ch. 13

•       Sexual assault examination records: Minn. Stat. § 145.1475

•       Reproductive health information: applicable state and federal protections

7.6 Copy of This Authorization

You are entitled to receive a copy of this completed authorization form. Please request a copy at the time of signing or contact us at info@directpayvirtualclinic.org.

7.7 Fees for Record Release

A reasonable, cost-based fee may be charged for copying and transmitting records in accordance with 45 C.F.R. § 164.524(c)(4) and Minn. Stat. § 144.292, Subd. 6. You will be notified of any applicable fees prior to release of records. No fee will be charged for records requested directly by the patient for their own use.

SECTION 8: PERSONAL REPRESENTATIVE OR LEGAL GUARDIAN

Complete this section ONLY if you are signing on behalf of the patient (e.g., as a parent of a minor, legal guardian, holder of a durable power of attorney for healthcare, or personal representative of a deceased patient's estate).

 

Representative Full Legal Name
Relationship to Patient
Mailing Address
Phone Number
Email Address
Legal Authority (check one)	☐ Parent of Minor Patient     ☐ Legal Guardian (court-appointed)     ☐ Durable Power of Attorney for Healthcare     ☐ Personal Representative of Deceased Patient’s Estate     ☐ Other: ___________________
Supporting Documentation (attach copy)	☐ Attached     ☐ On file with clinic     ☐ Will provide upon request

 

A personal representative or legal guardian signing this form on behalf of a patient must have legal authority to do so under applicable Minnesota or federal law. Minn. Stat. § 144.292 governs patient access rights and the rights of authorized representatives. The Clinic reserves the right to require documentation of legal authority before releasing records to a representative.

Note: Minors may have independent rights to authorize or withhold disclosure of certain health information under Minnesota law (Minn. Stat. § 144.341 et seq.), including records related to sexually transmitted infections, pregnancy, substance use treatment, and mental health services received without parental consent.

SECTION 9: PATIENT OR REPRESENTATIVE SIGNATURE

By signing below, I certify that:

1.     I have read and understand this Authorization for Release of Protected Health Information in its entirety;

2.     The information I have provided on this form is true and accurate to the best of my knowledge;

3.     I understand this authorization is voluntary and that my treatment will not be conditioned on signing;

4.     I understand my right to revoke this authorization at any time in writing, subject to the limitations described in Section 7.2;

5.     I understand that once information is disclosed to the recipient, it may no longer be protected by HIPAA;

6.     I have been given the opportunity to ask questions and have had them answered to my satisfaction;

7.     I am requesting the release of only those records and categories of information I have specifically identified in this form;

8.     I have received or been offered a copy of this completed authorization form.

 

Patient Full Legal Name (Print): ____________________________________   Date of Birth: _______________

Patient Signature: ______________________________________________   Date Signed: ___________________

 

If signed by a Personal Representative or Legal Guardian:

Representative Full Legal Name (Print): ____________________________________   Relationship: ___________________

Representative Signature: ______________________________________________   Date Signed: ___________________

Legal Authority / Basis for Signing: ________________________________________________________________________

 

 

FOR CLINIC USE ONLY — DO NOT COMPLETE BELOW THIS LINE

 

Date Request Received		Received By
Identity Verified By		Method of Verification
Records Released / Date		Released By
Method of Release	☐ Secure Fax     ☐ Encrypted Email     ☐ Patient Portal     ☐ Certified Mail     ☐ In Person Pickup     ☐ Other: ___________
Authorization Denied?	☐ Yes (reason): ______________________________________________________________________     ☐ No
Fee Charged		Fee Paid / Date
Revocation Received / Date		Processed By
Notes