Generate printable form(s) that authorize your healthcare provider to release your STI screening results directly to partners or others of your choosing.
This is a prototype tool that is not ready for real-world use. Do not use this tool for purposes other than to provide the author with feedback.
Terms of Use
This tool is not a substitute for a healthcare lawyer. If you do not completely understand and agree with the forms generated by this tool, do not use it.
Before using this tool I agree:
to read the agreement forms generated by this tool in their entirety before signing them,
to sign the forms only if I am certain I understand them and that they represent my wishes, and
to hold the creators of this tool harmless for any consequences of my use of the generated forms.
Healthcare Provider Authorized to Release Protected Health Information
The disclosure forms generated by this tool are not valid in California or Texas.
Patient Receiving Screening
Individual(s) Authorized to Receive Screening Results
Expiration of Authorization
Optional Clauses
HIPAA Authorization for Release of Protected Health Information
I, ,of ,born ,
(henceforth PATIENT)
authorize
my healthcare providerof in the state of
(henceforth PROVIDER) to release specific identifiable healthcare information to
my partnerof
(henceforth AUTHORIZED INDIVIDUAL) at phone number .
The specific identifiable healthcare information I am authorizing PROVIDER to release is to include all results of tests for sexual transmitted infections (STIs) and other infectious diseases that might be transmitted through close or intimate contact. This may include, but is not limited to, tests for STIs including HIV, HPV, HSV-1, HSV-2, Hepatitis A/B/C, Chlamydia, Gonorrhea, Syphilis, Mpox, or Mgen; as well as tests for infections that do not require intimate contact, such as COVID-19, Influenza (Flu), or RSV. This authorization excludes any health information unrelated to the spread of infectious disease.
I am authorizing PROVIDER to release the identifiable healthcare information to AUTHORIZED INDIVIDUAL by phone at their phone number. PROVIDER should also disclose the results if contacted by the authorized individual, whose identity can be verified by their knowledge of the following sequence of code words:
TEST
It is imperative that PROVIDER allow AUTHORIZED INDIVIDUAL to contact PROVIDER at their publicly-known phone number on this form () so that AUTHORIZED INDIVIDUAL may authenticate PROVIDER to confirm the authenticity of all test results.
PROVIDER should NOT notify AUTHORIZED INDIVIDUAL of any positive test result until PROVIDER has confirmed that I have received those results, or after 7 days have passed from the first attempt to notify me, whichever is sooner.
I understand that the information used and/or disclosed pursuant to this Authorization may be re-
disclosed by the recipient(s) of the information and may no longer be protected by the Health Insurance Portability
and Accountability Act Privacy Rule (45 CFR Part 164) and the Privacy Act of 1974 (5 USC 552a).
I can terminate this authorization at any time by submitting a written revocation to PROVIDER.
If not already terminated, this authorization automatically expires 7 day after the healthcare provider delivers screening panel(s) to AUTHORIZED INDIVIDUAL.
If not already terminated, this authorization automatically expires at 11:59PM local time in on .
I have read and fully understand this entire authorization, that it reflects my own choices, and that these choices are entirely voluntary. I will hold harmless the creators of this form for any consequences of my using it.