Autorización para el Uso o Divulgación de Información de Salud Protegida — Notas de Psicoterapia solamente
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A Spanish-language authorization form governing release of psychotherapy notes for Arizona Complete Health members; it explains scope, voluntary nature, revocation, fees, and expiration, and collects recipient and date details.
No material clinical or coverage changes in this revision.
Authorization and Coverage Criteria
Authorization Requirements
Conditions and elements required for a valid authorization and permitted disclosure of psychotherapy notes:
ALL of the following
- Authorization is limited to psychotherapy notes and may not be combined with any other authorization for release of protected health information (45 CFR § 164.508).
- Authorization must name the person(s), organization, or program permitted to disclose the information and the person(s) or organization to whom the information will be disclosed (include name and address).
Time frame selection
- All psychotherapy notes (select ‘All notes’).
- Psychotherapy notes for a specified date range (provide start and end dates).
- Other specified psychotherapy notes (describe topics/issues to be disclosed).
- Unless revoked earlier, the authorization expires 12 months after the date signed unless another expiration event or date is specified.
- Signing the authorization is voluntary; treatment, payment, enrollment, or eligibility will not be conditioned on signing.
- The member may revoke the authorization in writing, except to the extent action has already been taken; revocation must be sent to the person or entity permitted to disclose the information.
- Reasonable and permissible copying fees may be charged in accordance with state and federal law.
- Member or authorized representative signature and date are required. If signed by a representative, documentation of the representative's authority must be provided.
Provider / Release Actions
Psychotherapy Notes Release Authorization (Spanish)
Autorización para el Uso o Divulgación de Información de Salud Protegida — Notas de Psicoterapia solamente. Formulario en español que autoriza la divulgación únicamente de notas de psicoterapia a la persona u organización nombrada abajo. Esta autorización es voluntaria y separada de cualquier otra autorización para divulgar otro tipo de información de salud (45 CFR §164.508). El miembro o su representante puede revocar la autorización por escrito, excepto en la medida en que la divulgación ya se haya realizado. La divulgación adicional a terceros sin autorización previa está prohibida (A.R.S. § 12-2294(E)). Se pueden aplicar cargos razonables por copias conforme a la ley estatal y federal. El formulario debe incluir: nombre del miembro, ID de AHCCCS, domicilio, nombre/organización autorizada a divulgar la información, nombre/domicilio del destinatario de la información, y la razón de la divulgación (p. ej., petición del miembro u otra).
- Incluye solo notas de psicoterapia — no otros PHI
- Requiere autorización separada para cualquier otra información de salud (45 CFR §164.508)
- Firma voluntaria — no condiciona tratamiento, pago, inscripción o elegibilidad
- Revocación por escrito permitida, salvo acciones ya ejecutadas
- Prohibida la redivulgación a terceros sin autorización previa (A.R.S. § 12-2294(E))
- Pueden aplicarse cargos razonables por copias conforme a ley
Definitions
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