Page 60 - Privacy_Program

Employees and others DP130B.8 The authorization will be written in plain language.
with Access to PHI
Employees and others DP130B.9 The authorization document will allow participants to request that their PHI be
with Access to PHI used or disclosed for specific purposes.

Employees and others DP130B.10 When the organization initiates an authorization to use or disclose PHI for its
with Access to PHI own purposes, the organization will provide participants with any facts they
need to make an informed decision as to whether to allow release of the
information.
Employees and others DP130B.11 The authorization will not be combined with another document to create a
with Access to PHI compound authorization, unless:

DP130B.11a (a) the other document is a similar such authorization;

DP130B.11b (b) if the authorization is for the disclosure of psychotherapy notes, the other
document is also an authorization for the disclosure of psychotherapy notes; or
DP130B.11c (c) the authorization is for the use or disclosure of privacy restricted
information created for a research study, and is to be combined with another
written permission for the study.
Employees and others DP130B.12 Any authorization for the use or disclosure of PHI will contain the following:
with Access to PHI
DP130B.12a (a) a description of the information to be used or disclosed that identifies the
information in a specific and meaningful fashion;
DP130B.12b (b) the name or other specific identification of the person(s), or class of
persons, authorized to make the requested use or disclosure;
DP130B.12c (c) the name or other specific identification of the person(s), or class of persons,
to whom the organization may make the requested use or disclosure;
DP130B.12d (d) a description of each purpose of the requested use or disclosure;
DP130B.12e (e) an expiration date or an expiration event that relates to the participant or the
purpose of the use or disclosure;
DP130B.12f (f) a statement of the individual’s right to revoke the authorization in writing
and the exceptions to the right to revoke;
DP130B.12g (g) a description of how the participant may revoke the authorization;
DP130B.12h (h) a statement that the entity will not condition treatment, payment,
enrollment in a health plan, or eligibility for benefits on the provision of an
authorization, except as permitted by law.
DP130B.12i (i) a statement that information used or disclosed pursuant to the
authorization may be subject to redisclosure by the recipient and no longer be
protected by 45 C.F.R. Part 164;
DP130B.12j (j) the signature of the participant and date.
Employees and others DP130B.13 In the event that the authorization is signed by a personal representative of the
with Access to PHI participant, the authorization will contain a description of the representative’s
authority to act for the participant.
Employees and others DP130B.14 The organization will provide the participant with a copy of the signed
with Access to PHI authorization.

Employees and others DP130B.15 The organization will invalidate the authorization if:
with Access to PHI

GES CONFIDENTIAL 56