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Authorization to Request, Use, or Release Member Psychotherapy Notes Form

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This form is used to instruct HMSA to send or receive copies of your psychotherapy notes that we may have to get to or from an individual or organization. The individual or organization sending or receiving your psychotherapy notes will only be allowed to send or receive the notes if you complete this form.

Please note that once your psychotherapy notes are disclosed to the person or organization you indicate in Part C of this form, the information in their possession may no longer be protected by privacy laws. This form may only be signed by the member or a person with the legal authority to sign for the member.

Please print and complete the form in its entirety. Incomplete forms won’t be processed and will be returned.

Part A - Member information

Complete all information in this section for the member whose records are to be amended. All fields are required.

  • Last Name – Enter legal last name as it appears on the HMSA membership card.
  • First Name – Enter legal first name as it appears on the HMSA membership card.
  • MI – Enter middle initial(s).
  • Address – Enter street address (e.g., “123 Any Street”).
  • City – Enter name of the city (e.g., “Honolulu”).
  • State – Enter state abbreviation (e.g., “HI”).
  • ZIP Code – Enter five-digit ZIP code. If known, include ZIP +4.
  • Email – Enter an email address, if available.
  • Home Phone – Enter a home telephone number with area code.
  • Cell Phone – Enter a cell phone number with area code.
  • HMSA Subscriber Number(s) – Please include the HMSA subscriber number(s) as indicated on the HMSA membership card. If more than one member ID exists, include all HMSA IDs that this authorization should apply to.
  • Birth Date – Enter the birth date in the format mm/dd/yyyy (e.g., 07/15/1990).

Part B - Request type

Select one of the following three options. Only one selection should be chosen per form.

  • Request Notes – Selecting this option allows HSMA to obtain copies of your psychotherapy notes from the individual or organization indicated in Part C of this form.
  • Release Notes – Selecting this option allows HMSA to send copies of your psychotherapy notes to the individual or organization indicated in Part C of this form.
  • Revoke a Previous Authorization – Selecting this option will cancel a previously submitted authorization to request or release your psychotherapy notes.

Part C - Person or organization authorized to request/release to

Complete all information about the individual or organization that will request or release your psychotherapy notes.

  • Last Name – Enter the last name of the individual sending or receiving your information.
  • First Name – Enter the first name of the individual sending or receiving your information.
  • MI – Enter the middle initial of the individual sending or receiving your information.
  • Address – Enter street address (e.g., “123 Any Street”) of the individual or organization sending or receiving your information.
  • City – Enter name of the city (e.g., “Honolulu”) of the individual or organization sending or receiving your information.
  • State – Enter state abbreviation (e.g., “HI”) of the individual or organization sending or receiving your information.
  • ZIP Code – Enter five-digit ZIP code of the individual or organization sending or receiving your information. If known, include ZIP +4.
  • Organization Name – If sending or receiving your information to/from an organization, state the name of the organization.
  • Telephone – Enter a telephone number with area code.
  • Fax – Enter a fax number with area code, if applicable.

Part D - Appointment purpose and expiration

  • Purpose – Specifically and meaningfully indicate the reason that the request or release of your notes will be made. Include any restrictions such as specific date ranges or events (e.g., “Release all psychotherapy notes from 1/1/2010 to 3/1/2010”).
  • Expiration – This authorization will be effective beginning on the date it was signed by the member and will expire on the earliest of the following dates:
    • One year from the date the form was signed.
    • A date specified by the member (and less than one year).
    • A specific event as described by the member (which occurs in less than one year from the date the form was signed).
  • HMSA will contact you before the form’s expiration date to ask if authorization should be extended. If you don’t reply, the authorization will expire on the form’s indicated expiration date.

Part E - Your individual rights

This section of the form describes your rights as indicated by applicable state and/or federal laws.

Part F - Signature

The member should print their name and sign at the bottom of the form. If a person with legal authority other than the member is signing the form, please print the name of the person with legal authority and the relationship of the person to the member, and provide a copy of documentation verifying the legal authority (e.g., a copy of a legal power of attorney).

Return the completed form to the following address:

HMSA Privacy Office
P.O. Box 860
Honolulu, HI 96808-0860