0920-0891 WTC Health Program HIPAA Authorization - Third Parties

World Trade Center Health Program

General HIPAA Authorization for Disclosures to Third Parties

INSTRUCTIONS: This form must be filled out in its entirety by a WTC Health Program applicant/member or their personal representative. In addition to the form itself, please include:

• Documentation verifying the identity of the recipient, such as a copy of a driver’s license, if you are not requesting records to be sent to yourself

• (Personal Representatives ONLY) Documentation demonstrating your legal authority to act on behalf of the applicant/member, such as a copy of a Power of Attorney authorization, and documentation verifying your identity as the personal representative, such as a copy of a driver’s license

Please return all documents to the WTC Health Program via mail ATTN: WTC Health Program Privacy Officer at 395 E Street SW, Suite 9200 Washington, DC 20201 or via fax at 404-448-4485.

I, ______________________________________________, give permission to the U.S. Department of

(name of applicant/member)

Health and Human Services, Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH), World Trade Center (WTC) Health Program¹ to disclose the following protected health information related to:

________________________________________________________________________

(Name of applicant/member and wtchp member id (911#), if known)

________________________________________________________________________

(date of birth of applicant/member)

To the following individual or entity:

________________________________________________________________________

(name of recipient)

________________________________________________________________________

(address of recipient)

________________________________________________________________________

(Telephone number of recipient)

________________________________________________________________________

(email address of recipient, if known)

For the following purpose:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The information to be disclosed will be the minimum necessary for the third party to carry out its purpose and may include (please check all that apply and describe if there are any exclusions within each checked category):

• WTC Health Program certification decision letters, including certification denial decisions/letters (This letter lists conditions for which the WTC Health Program has determined are related to or medically associated with the member’s 9/11 exposures)

Please list any exclusions to the WTC Health Program’s disclosure of its certification decisions/letters:

______________________________________________________________________________

• WTC Health Program enrollment decision letters (This letter confirms a member’s successful enrollment in the WTC Health Program) and application materials (documents that the WTC Health Program used to determine the individual’s eligibility for enrollment)

Please list any exclusions to the WTC Health Program’s disclosure of its enrollment application materials:

______________________________________________________________________________

And, if requested:

• Medical Records, including treatment and diagnostic records. Please note that medical records requests will be forwarded to the member’s clinic for fulfillment.

Please list any exclusions to the WTC Health Program’s disclosure of its Medical Records:

_____________________________________________________________________________________

• Other Records: _________________________________________________________________

Please list any exclusions to the WTC Health Program’s disclosure of its Other Records:

_____________________________________________________________________________________

• Other Exclusions: _____________________________________________________________________

This authorization expires when the information requested is provided to the above-named recipient, or at such time as I exercise my right to revoke this authorization. I may revoke this authorization in writing at any time by sending written notification to the Program: ATTN: WTC Health Program Privacy Officer 395 E Street SW, Suite 9200 Washington, DC 20201. Any disclosure of information by the WTC Health Program made prior to the WTC Health Program’s receipt of my written request to revoke this authorization will be governed by this authorization to the extent that action has already been taken based on this authorization.

Signing this authorization is voluntary. The WTC Health Program may not condition treatment, payment, enrollment, or eligibility for benefits on the signing of this authorization. The information disclosed under this authorization might be further disclosed by the recipient(s); such additional disclosures by third parties are not subject to, nor protected by, this authorization. The WTC Health Program will give me a copy of this signed authorization, upon request. (Requests may be made in writing to the above address.)

I hereby authorize the WTC Health Program to disclose the above described health information to

______________________________________________, for the above described purpose(s).

(name of recipient)

By my signature I attest that I have provided truthful and accurate information and that I understand the following: Any person who knowingly makes any false statement, misrepresentation, concealment of fact, or any other act of fraud to the United State Government is subject to civil and/or administrative remedies as well as felony criminal prosecution and may, under appropriate criminal provisions, be punished by a fine or imprisonment or both pursuant to 18 U.S.C. § 1001.

NAME: ______________________________________________________

(PRINT)

ADDRESS: ______________________________________________________

______________________________________________________

PHONE: ______________________________________________________

EMAIL: ______________________________________________________

DATE: ______________________________________________________

SIGNATURE: ______________________________________________________

1 For purposes of this document, all references to the WTC Health Program include NIOSH to the extent that it administers the WTC Health Program, as well as all contractors and business associates of NIOSH who conduct activities on behalf of the WTC Health Program, including but not limited to the Clinical Centers of Excellence and Nationwide Provider Network.

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