HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.
Parts 160 and 164)
The Health Insurance Portability and Accountability Act (HIPAA) establishes patient rights and
protections associated with the use of protected health information. HIPAA provides patient
protections related to the electronic transmission of data (“the transaction rules”), the keeping
and use of patient records (“privacy rules”), and storage and access to health care records (“the
security rules”). HIPAA applies to all health care providers, including mental health care
providers. Providers and health care agencies are required to provide patients a notification of
their privacy rights as it relates to their health care records.
This Patient Notification of Privacy Rights informs you of your rights. Please carefully read this
Patient Notification. It is important that you know and understand the patient protections HIPAA
affords you as a patient.
In mental health care, confidentiality and privacy are central to the success of the therapeutic
relationship; therefore, I will do all we can do to protect the privacy of your mental health
records. If you have questions regarding matters discussed in this Patient Notification, please
do not hesitate to ask.
I. Preamble
Records are kept documenting your care as required by law, professional standards, and other
review procedures. HIPAA clearly defines what kind of information is to be included in your
“designated medical record” or “case record” as well as some material, known as
“Psychotherapy Notes” which is not accessible to insurance companies and other third-party
reviewers. HIPAA provides privacy protections about your personal health information, which is
called “protected health information (PHI)” which could personally identify you. PHI consists of
three (3) components: treatment, payment, and health care operations.
Treatment refers to activities/sessions I provide, coordinate or manage your mental health care
service or other services related to your health care. Examples include a counseling session or
communication with your primary care physician about your medication or overall medical
condition.
Payment is when Elyse Etapa, LLC obtains reimbursement for your mental health care or other
services related to your health care.
Health care operations are activities related to my performance such as quality assurance. The
use of your protected health information refers to activities my agency conducts for scheduling
appointments, keeping records, and other tasks related to your care. Disclosures refer to
activities you authorize such as the sending of your protected health information to other parties
(i.e., your insurance company).