IM-136 10/17/03 HIPAA COMPLIANT DISCLOSURE OF HEALTH INFORMATION FORM

M E M O R A N D U M

IM-136 10/17/03 HIPAA COMPLIANT DISCLOSURE OF HEALTH INFORMATION FORM

SUBJECT:

HIPAA COMPLIANT DISCLOSURE OF HEALTH INFORMATION FORM

DISCUSSION:

Effective immediately begin using Form MO 650-2616 (01-03), Authorization for Disclosure of Consumer Medical/Health Information, when requesting health information from medical providers or other agencies. A copy of the form is attached to this memo.

The Authorization for Disclosure Form is available on the Intranet.

The IM-60 is being revised to use as a cover letter with the Authorization for Disclosure. A separate memo will be issued when the IM-60 is complete.

NECESSARY ACTION:

Share this memorandum with appropriate staff as soon as possible.

Begin using Form MO 650-2616 (01-03) immediately.

GLS
Attachment

Electronic Form available at Forms Download Page

IM-135

[ 2003 Memorandums ]

IM-137