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HPD Form - Protected Health Information (PHI) (Read 1572 times)

surfmaster

HPD Form - Protected Health Information (PHI)
« on: August 31, 2022, 11:14:49 AM »
I've got a friend who is considering apply for a rifle permit. I have a question about the HPD form titled "Authorization for Use or Disclosure of Protected Health Information), https://www.honolulupd.org/wp-content/uploads/2020/09/mentalhealthwaiver_HPD089AR02_14yellow.pdf?fbclid=IwAR2Fkkf1qjMuci4MrT6n92KlMv9sNVsIDJwVGdsDKhZN0mQ6LF3vimpEVcs.

What information goes in the upper right section of the form titled, "Name of Individual/Organization (Other than AMDH) disclosing PHI"?

Is this your own doctor? Or is it another employee or doctor releasing your information not directly affiliated with the Hawaii Adult Mental Health Division?
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Flapp_Jackson

Re: HPD Form - Protected Health Information (PHI)
« Reply #1 on: August 31, 2022, 11:32:59 AM »
Quote from: surfmaster on August 31, 2022, 11:14:49 AM
I've got a friend who is considering apply for a rifle permit. I have a question about the HPD form titled "Authorization for Use or Disclosure of Protected Health Information), https://www.honolulupd.org/wp-content/uploads/2020/09/mentalhealthwaiver_HPD089AR02_14yellow.pdf?fbclid=IwAR2Fkkf1qjMuci4MrT6n92KlMv9sNVsIDJwVGdsDKhZN0mQ6LF3vimpEVcs.

What information goes in the upper right section of the form titled, "Name of Individual/Organization (Other than AMDH) disclosing PHI"?

Is this your own doctor? Or is it another employee or doctor releasing your information not directly affiliated with the Hawaii Adult Mental Health Division?

This is just a form letter giving permission to Hawaii mental health agencies to disclose your information regarding mental health and substance abuse/addiction to the police department.

You just sign the bottom.  Unless you are a minor or someone outside the state's AMHD with related information, nothing else is filled in.

There are separate forms giving your doctor/HMO permission to send your records to HPD.
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The reasonable man adapts himself to the world;
the unreasonable one persists in trying to adapt the world to himself.
Therefore, all progress depends on the unreasonable man.
-- George Bernard Shaw

6716J

Re: HPD Form - Protected Health Information (PHI)
« Reply #2 on: August 31, 2022, 01:15:01 PM »
Heres a fillable blank one. With minor edit to the authorization event termination. I wanted an end to the authorization

Print it on yellow paper.
« Last Edit: September 01, 2022, 12:22:07 PM by 6716J »
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I'd rather have a bottle in front of me, than a frontal lobotomy.

surfmaster

Re: HPD Form - Protected Health Information (PHI)
« Reply #3 on: August 31, 2022, 10:45:41 PM »
Flapp and 6716J, thanks for your insightful replies. 
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dogman

Re: HPD Form - Protected Health Information (PHI)
« Reply #4 on: August 31, 2022, 11:30:22 PM »
Quote from: surfmaster on August 31, 2022, 11:14:49 AM
What information goes in the upper right section of the form titled, "Name of Individual/Organization (Other than AMDH) disclosing PHI"?
Leave that blank

Applicant fills out all other blanks

This form goes to the State Hospital in Kaneohe. If you plead insanity in a court of law, you might end up there . . . I believe
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