Sample only, this is not intended as legal advice
Psychotherapy Notes Authorization Draft
[Name of Covered Entity]
Effective: April 14, 2003
AUTHORIZATION FOR THE USE AND DISCLOSURE OF PSYCHOTHERAPY NOTES
I authorize [Name of Covered Entity] or [its reinsurers and consumer reporting agencies, or any of] its authorized representatives, to obtain, use, and/or disclose Psychotherapy Notes about me as indicated below.
[TI1][Name of Covered Entity]may obtain and maintain Psychotherapy Notes about me to perform specific functions. This authorization describes the type of information that is collected and my rights regarding how that information can be used.
Psychotherapy Notes mean, notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session, and that are separated from the rest of the individual’s medical record.
Psychotherapy Notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Psychotherapy Notes may be used by [Name of Covered Entity]employees and business associates as may be necessary to perform activities such as determination of benefit level usage related to the [health benefit plan][provision of health plan benefits].
[Name of Covered Entity] is committed to the privacy of your Protected Health Information (PHI) and has required all business associates to agree in writing to those same protections. Despite these efforts [we are required by law to advise you that] your information may [at some point fall outside of these protections][be re-disclosed and would no longer be protected].
I understand that I have a right to revoke this authorization at any timeand my request must be in writing. Please refer to the [Name of Covered Entity] Privacy Notice for additional information on how to revoke this authorization. I am aware that my PHI already used and disclosed will not be affected by my revocation.
I agree this authorization will be valid [for twenty-four (24) months from the date signed][until all benefits under this plan have been determined].
A simulated, faxed or copied image of this authorization shall be as valid as the original.
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SignatureDate (Month/Day/Year)
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Name
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Name of Personal RepresentativeRelationship to Patient
[TI1]1