The Consent To Share Medical Information With Family Member Letter is essential in healthcare settings where family members need access to a patient's medical information for care coordination or support. This document, governed by HIPAA and state-specific regulations in the United States, provides healthcare providers with the legal authority to discuss protected health information with designated family members. It's particularly important in situations involving elderly care, chronic illness management, or when patients need family support in managing their healthcare. The letter must include specific elements required by HIPAA, such as the scope of information to be shared, duration of authorization, and the right to revoke consent.
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1. Patient Information: Full name, date of birth, contact information, and medical record number of the patient
2. Authorized Family Member Details: Full name, relationship to patient, and contact information of the family member being authorized
3. Scope of Information: Specific description of what medical information can be shared with the authorized family member
4. Duration of Authorization: Time period for which the authorization is valid, including start and end dates
5. Rights and Revocation: Statement of patient's right to revoke consent and procedure for doing so
6. Authorization Statement: Clear statement of voluntary consent and understanding of the information sharing terms
7. Signature Block: Space for patient signature, date, and any required witness signatures
1. Special Categories Authorization: Additional authorization for sensitive information such as mental health records, HIV/AIDS status, or substance abuse treatment
2. Emergency Contact Designation: Additional provisions if the authorized family member is also serving as an emergency contact
3. Healthcare Provider Specifications: Specific list of healthcare providers authorized to share information with the family member
1. HIPAA Privacy Notice: Summary of patient rights under HIPAA and relevant privacy practices
2. State Privacy Rights Summary: Summary of additional privacy rights under applicable state law
3. Provider Contact Information: Comprehensive list of healthcare providers and their contact details
Relevant legal definitions
Protected Health Information (PHI)
Healthcare Provider
Authorized Family Member
Authorization Period
Medical Records
Covered Entity
Disclosure
Treatment Information
Health Care Operations
Minimum Necessary Information
Revocation
Electronic Health Record (EHR)
Personal Representative
Notice of Privacy Practices
Confidential Communications
Mental Health Information
Substance Use Disorder Information
HIV/AIDS-Related Information
Genetic Information
Emergency Contact
Healthcare Provider
Authorized Family Member
Authorization Period
Medical Records
Covered Entity
Disclosure
Treatment Information
Health Care Operations
Minimum Necessary Information
Revocation
Electronic Health Record (EHR)
Personal Representative
Notice of Privacy Practices
Confidential Communications
Mental Health Information
Substance Use Disorder Information
HIV/AIDS-Related Information
Genetic Information
Emergency Contact
Clauses
Authorization
Consent
Privacy
Disclosure Limitations
Information Access
Duration and Expiration
Revocation Rights
Confidentiality
Protected Health Information
Release of Information
Record Maintenance
Electronic Communications
Emergency Access
Healthcare Provider Rights
Family Member Obligations
Redisclosure Restrictions
State-Specific Requirements
Special Categories of Information
Consent
Privacy
Disclosure Limitations
Information Access
Duration and Expiration
Revocation Rights
Confidentiality
Protected Health Information
Release of Information
Record Maintenance
Electronic Communications
Emergency Access
Healthcare Provider Rights
Family Member Obligations
Redisclosure Restrictions
State-Specific Requirements
Special Categories of Information
Relevant Industries
Relevant Teams
Relevant Roles
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