|
Code
|
Display
|
Definition
|
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cric
|
Common
Rule
Informed
Consent
|
45
CFR
part
46
§46.116
General
requirements
for
informed
consent;
and
§46.117
Documentation
of
informed
consent.
https://www.gpo.gov/fdsys/pkg/FR-2017-01-19/pdf/2017-01058.pdf
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illinois-minor-procedure
|
Illinois
Consent
by
Minors
to
Medical
Procedures
|
The
consent
to
the
performance
of
a
medical
or
surgical
procedure
by
a
physician
licensed
to
practice
medicine
and
surgery,
a
licensed
advanced
practice
nurse,
or
a
licensed
physician
assistant
executed
by
a
married
person
who
is
a
minor,
by
a
parent
who
is
a
minor,
by
a
pregnant
woman
who
is
a
minor,
or
by
any
person
18
years
of
age
or
older,
is
not
voidable
because
of
such
minority,
and,
for
such
purpose,
a
married
person
who
is
a
minor,
a
parent
who
is
a
minor,
a
pregnant
woman
who
is
a
minor,
or
any
person
18
years
of
age
or
older,
is
deemed
to
have
the
same
legal
capacity
to
act
and
has
the
same
powers
and
obligations
as
has
a
person
of
legal
age.
Consent
by
Minors
to
Medical
Procedures
Act.
(410
ILCS
210/0.01)
(from
Ch.
111,
par.
4500)
Sec.
0.01.
Short
title.
This
Act
may
be
cited
as
the
Consent
by
Minors
to
Medical
Procedures
Act.
(Source:
P.A.
86-1324.)
http://www.ilga.gov/legislation/ilcs/ilcs3.asp?ActID=1539&ChapterID=35
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hipaa-auth
|
HIPAA
Authorization
|
HIPAA
45
CFR
Section
164.508
Uses
and
disclosures
for
which
an
authorization
is
required.
(a)
Standard:
Authorizations
for
uses
and
disclosures.
(1)
Authorization
required:
General
rule.
Except
as
otherwise
permitted
or
required
by
this
subchapter,
a
covered
entity
SJALL
not
use
or
disclose
protected
health
information
without
an
authorization
that
is
valid
under
this
section.
When
a
covered
entity
obtains
or
receives
a
valid
authorization
for
its
use
or
disclosure
of
protected
health
information,
such
use
or
disclosure
must
be
consistent
with
such
authorization.
Usage
Note:
Authorizations
governed
under
this
regulation
meet
the
definition
of
an
opt
in
class
of
consent
directive.
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hipaa-npp
|
HIPAA
Notice
of
Privacy
Practices
|
§
164.520
Notice
of
privacy
practices
for
protected
health
information.
(1)
Right
to
notice.
Except
as
provided
by
paragraph
(a)(2)
or
(3)
of
this
section,
an
individual
has
a
right
to
adequate
notice
of
the
uses
and
disclosures
of
protected
health
information
that
may
be
made
by
the
covered
entity,
and
of
the
individual's
rights
and
the
covered
entity's
legal
duties
with
respect
to
protected
health
information.
Usage
Note:
Restrictions
governed
under
this
regulation
meet
the
definition
of
an
implied
with
an
opportunity
to
dissent
class
of
consent
directive.
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hipaa-restrictions
|
HIPAA
Restrictions
|
HIPAA
45
CFR
§
164.510
-
Uses
and
disclosures
requiring
an
opportunity
for
the
individual
to
agree
or
to
object.
A
covered
entity
may
use
or
disclose
protected
health
information,
provided
that
the
individual
is
informed
in
advance
of
the
use
or
disclosure
and
has
the
opportunity
to
agree
to
or
prohibit
or
restrict
the
use
or
disclosure,
in
accordance
with
the
applicable
requirements
of
this
section.
The
covered
entity
may
orally
inform
the
individual
of
and
obtain
the
individual's
oral
agreement
or
objection
to
a
use
or
disclosure
permitted
by
this
section.
Usage
Note:
Restrictions
governed
under
this
regulation
meet
the
definition
of
an
opt
out
with
exception
class
of
consent
directive.
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hipaa-research
|
HIPAA
Research
Authorization
|
HIPAA
45
CFR
§
164.508
-
Uses
and
disclosures
for
which
an
authorization
is
required.
(a)
Standard:
Authorizations
for
uses
and
disclosures.
(3)
Compound
authorizations.
An
authorization
for
use
or
disclosure
of
protected
health
information
SHALL
not
NOT
be
combined
with
any
other
document
to
create
a
compound
authorization,
except
as
follows:
(i)
An
authorization
for
the
use
or
disclosure
of
protected
health
information
for
a
research
study
may
be
combined
with
any
other
type
of
written
permission
for
the
same
or
another
research
study.
This
exception
includes
combining
an
authorization
for
the
use
or
disclosure
of
protected
health
information
for
a
research
study
with
another
authorization
for
the
same
research
study,
with
an
authorization
for
the
creation
or
maintenance
of
a
research
database
or
repository,
or
with
a
consent
to
participate
in
research.
Where
a
covered
health
care
provider
has
conditioned
the
provision
of
research-related
treatment
on
the
provision
of
one
of
the
authorizations,
as
permitted
under
paragraph
(b)(4)(i)
of
this
section,
any
compound
authorization
created
under
this
paragraph
must
clearly
differentiate
between
the
conditioned
and
unconditioned
components
and
provide
the
individual
with
an
opportunity
to
opt
in
to
the
research
activities
described
in
the
unconditioned
authorization.
Usage
Notes:
See
HHS
http://www.hhs.gov/hipaa/for-professionals/special-topics/research/index.html
and
OCR
http://www.hhs.gov/hipaa/for-professionals/special-topics/research/index.html
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hipaa-self-pay
|
HIPAA
Self-Pay
Restriction
|
HIPAA
45
CFR
§
164.522(a)
Right
To
Request
a
Restriction
of
Uses
and
Disclosures.
(vi)
A
covered
entity
must
agree
to
the
request
of
an
individual
to
restrict
disclosure
of
protected
health
information
about
the
individual
to
a
health
plan
if:
(A)
The
disclosure
is
for
the
purpose
of
carrying
out
payment
or
health
care
operations
and
is
not
otherwise
required
by
law;
and
(B)
The
protected
health
information
pertains
solely
to
a
health
care
item
or
service
for
which
the
individual,
or
person
other
than
the
health
plan
on
behalf
of
the
individual,
has
paid
the
covered
entity
in
full.
Usage
Note:
Restrictions
governed
under
this
regulation
meet
the
definition
of
an
opt
out
with
exception
class
of
consent
directive.
Opt
out
is
limited
to
disclosures
to
a
payer
for
payment
and
operations
purpose
of
use.
See
HL7
HIPAA
Self-Pay
code
in
ActPrivacyLaw
(2.16.840.1.113883.1.11.20426).
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mdhhs-5515
|
Michigan
MDHHS-5515
Consent
to
Share
Behavioral
Health
Information
for
Care
Coordination
Purposes
|
On
January
1,
2015,
the
Michigan
Department
of
Health
and
Human
Services
(MDHHS)
released
a
standard
consent
form
for
the
sharing
of
health
information
specific
to
behavioral
health
and
substance
use
treatment
in
accordance
with
Public
Act
129
of
2014.
In
Michigan,
while
providers
are
not
required
to
use
this
new
standard
form
(MDHHS-5515),
they
are
required
to
accept
it.
Note:
Form
is
available
at
http://www.michigan.gov/documents/mdhhs/Consent_to_Share_Behavioral_Health_Information_for_Care_Coordination_Purposes_548835_7.docx
For
more
information
see
http://www.michigan.gov/documents/mdhhs/Behavioral_Health_Consent_Form_Background_Information_548864_7.pdf
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nyssipp
|
New
York
State
Surgical
and
Invasive
Procedure
Protocol
|
The
New
York
State
Surgical
and
Invasive
Procedure
Protocol
(NYSSIPP)
applies
to
all
operative
and
invasive
procedures
including
endoscopy,
general
surgery
or
interventional
radiology.
Other
procedures
that
involve
puncture
or
incision
of
the
skin,
or
insertion
of
an
instrument
or
foreign
material
into
the
body
are
within
the
scope
of
the
protocol.
This
protocol
also
applies
to
those
anesthesia
procedures
either
prior
to
a
surgical
procedure
or
independent
of
a
surgical
procedure
such
as
spinal
facet
blocks.
Example:
Certain
'minor'
procedures
such
as
venipuncture,
peripheral
IV
placement,
insertion
of
nasogastric
tube
and
foley
catheter
insertion
are
not
within
the
scope
of
the
protocol.
From
http://www.health.ny.gov/professionals/protocols_and_guidelines/surgical_and_invasive_procedure/nyssipp_faq.htm
Note:
HHC
100B-1
Form
is
available
at
http://www.downstate.edu/emergency_medicine/documents/Consent_CT_with_contrast.pdf
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|
va-10-0484
|
VA
Form
10-0484
|
VA
Form
10-0484
Revocation
for
Release
of
Individually-Identifiable
Health
Information
enables
a
veteran
to
revoke
authorization
for
the
VA
to
release
specified
copies
of
individually-identifiable
health
information
with
the
non-VA
health
care
provider
organizations
participating
in
the
eHealth
Exchange
and
partnering
with
VA.
Comment:
Opt-in
Consent
Directive
with
status
=
rescinded
(aka
'revoked').
Note:
Form
is
available
at
http://www.va.gov/vaforms/medical/pdf/vha-10-0484-fill.pdf
|
|
va-10-0485
|
VA
Form
10-0485
|
VA
Form
10-0485
Request
for
and
Authorization
to
Release
Protected
Health
Information
to
eHealth
Exchange
enables
a
veteran
to
request
and
authorize
a
VA
health
care
facility
to
release
protected
health
information
(PHI)
for
treatment
purposes
only
to
the
communities
that
are
participating
in
the
eHealth
Exchange,
VLER
Directive,
and
other
Health
Information
Exchanges
with
who
VA
has
an
agreement.
This
information
may
consist
of
the
diagnosis
of
Sickle
Cell
Anemia,
the
treatment
of
or
referral
for
Drug
Abuse,
treatment
of
or
referral
for
Alcohol
Abuse
or
the
treatment
of
or
testing
for
infection
with
Human
Immunodeficiency
Virus.
This
authorization
covers
the
diagnoses
that
I
may
have
upon
signing
of
the
authorization
and
the
diagnoses
that
I
may
acquire
in
the
future
including
those
protected
by
38
U.S.C.
7332.
Comment:
Opt-in
Consent
Directive.
Note:
Form
is
available
at
http://www.va.gov/vaforms/medical/pdf/10-0485-fill.pdf
|
|
va-10-5345
|
VA
Form
10-5345
|
VA
Form
10-5345
Request
for
and
Authorization
to
Release
Medical
Records
or
Health
Information
enables
a
veteran
to
request
and
authorize
the
VA
to
release
specified
copies
of
protected
health
information
(PHI),
such
as
hospital
summary
or
outpatient
treatment
notes,
which
may
include
information
about
conditions
governed
under
Title
38
Section
7332
(drug
abuse,
alcoholism
or
alcohol
abuse,
testing
for
or
infection
with
HIV,
and
sickle
cell
anemia).
Comment:
Opt-in
Consent
Directive.
Note:
Form
is
available
at
http://www.va.gov/vaforms/medical/pdf/vha-10-5345-fill.pdf
|
|
va-10-5345a
|
VA
Form
10-5345a
|
VA
Form
10-5345a
Individuals'
Request
for
a
Copy
of
Their
Own
Health
Information
enables
a
veteran
to
request
and
authorize
the
VA
to
release
specified
copies
of
protected
health
information
(PHI),
such
as
hospital
summary
or
outpatient
treatment
notes.
Note:
Form
is
available
at
http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-fill.pdf
|
va-10-5345a-MHV
va-10-5345a-mhv
|
VA
Form
10-5345a-MHV
|
VA
Form
10-5345a-MHV
Individual’s
Request
for
a
Copy
of
their
own
health
information
from
MyHealtheVet
enables
a
veteran
to
receive
a
copy
of
all
available
personal
health
information
to
be
delivered
through
the
veteran’s
My
HealtheVet
account.
Note:
Form
is
available
at
http://www.va.gov/vaforms/medical/pdf/vha-10-5345a-MHV-fill.pdf
|
|
va-10-10116
|
VA
Form
10-10-10116
|
VA
Form
10-10116
Revocation
of
Authorization
for
Use
and
Release
of
Individually
Identifiable
Health
Information
for
Veterans
Health
Administration
Research.
Comment:
Opt-in
with
Restriction
Consent
Directive
with
status
=
'completed'.
Note:
Form
is
available
at
http://www.northerncalifornia.va.gov/northerncalifornia/services/rnd/docs/vha-10-10116.pdf
|
|
va-21-4142
|
VA
Form
21-4142
|
VA
Form
21-4142
(Authorization
and
Consent
to
Release
Information
to
the
Department
of
Veterans
Affairs
(VA)
enables
a
veteran
to
authorize
the
US
Veterans
Administration
[VA]
to
request
veteran’s
health
information
from
non-VA
providers.
Aka
VA
Compensation
Application
Note:
Form
is
available
at
http://www.vba.va.gov/pubs/forms/VBA-21-4142-ARE.pdf
.
For
additional
information
regarding
VA
Form
21-4142,
refer
to
the
following
website:
www.benefits.va.gov/compensation/consent_privateproviders
|
|
ssa-827
|
SSA
Authorization
to
Disclose
|
SA
Form
SSA-827
(Authorization
to
Disclose
Information
to
the
Social
Security
Administration
(SSA)).
Form
is
available
at
https://www.socialsecurity.gov/forms/ssa-827-inst-sp.pdf
|
|
dch-3927
|
Michigan
behavior
and
mental
health
consent
|
Michigan
DCH-3927
Consent
to
Share
Behavioral
Health
Information
for
Care
Coordination
Purposes,
which
combines
42
CFR
Part
2
and
Michigan
Mental
Health
Code,
Act
258
of
1974.
Form
is
available
at
http://www.michigan.gov/documents/mdch/DCH-3927_Consent_to_Share_Health_Information_477005_7.docx
|
|
squaxin
|
Squaxin
Indian
behavioral
health
and
HIPAA
consent
|
Squaxin
Indian
HIPAA
and
42
CFR
Part
2
Consent
for
Release
and
Exchange
of
Confidential
Information,
which
permits
consenter
to
select
healthcare
record
type
and
types
of
treatment
purposes.
This
consent
requires
disclosers
and
recipients
to
comply
with
42
C.F.R.
Part
2,
and
HIPAA
45
C.F.R.
parts
160
and
164.
It
includes
patient
notice
of
the
refrain
policy
not
to
disclose
without
consent,
and
revocation
rights.
https://www.ncsacw.samhsa.gov/files/SI_ConsentForReleaseAndExchange.PDF
|
|
nl-lsp
|
NL
LSP
Permission
|
LSP
(National
Exchange
Point)
requires
that
providers,
hospitals
and
pharmacy
obtain
explicit
permission
[opt-in]
from
healthcare
consumers
to
submit
and
retrieve
all
or
only
some
of
a
subject
of
care’s
health
information
collected
by
the
LSP
for
purpose
of
treatment,
which
can
be
revoked.
Without
permission,
a
provider
cannot
access
LSP
information
even
in
an
emergency.
The
LSP
provides
healthcare
consumers
with
accountings
of
disclosures.
https://www.vzvz.nl/uploaded/FILES/htmlcontent/Formulieren/TOESTEMMINGSFORMULIER.pdf,
https://www.ikgeeftoestemming.nl/en,
https://www.ikgeeftoestemming.nl/en/registration/find-healthcare-provider
|
|
at-elga
|
AT
ELGA
Opt-in
Consent
|
Pursuant
to
Sec.
2
no.
9
Health
Telematics
Act
2012,
ELGA
Health
Data
(
“ELGA-Gesundheitsdaten”)
=
Medical
documents.
Austria
opted
for
an
opt-out
approach.
This
means
that
a
person
is
by
default
‘ELGA
participant’
unless
he/she
objects.
ELGA
participants
have
the
following
options:
General
opt
out:
No
participation
in
ELGA,
Partial
opt-out:
No
participation
in
a
particular
ELGA
application,
e.g.
eMedication
and
Case-specific
opt-out:
No
participation
in
ELGA
only
regarding
a
particular
case/treatment.
There
is
the
possibility
to
opt-in
again.
ELGA
participants
can
also
exclude
the
access
of
a
particular
ELGA
healthcare
provider
to
a
particular
piece
of
or
all
of
their
ELGA
data.
http://ec.europa.eu/health/ehealth/docs/laws_austria_en.pdf
|
|
nih-hipaa
|
HHS
NIH
HIPAA
Research
Authorization
|
Guidance
and
template
form
https://privacyruleandresearch.nih.gov/pdf/authorization.pdf
|
|
nci
|
NCI
Cancer
Clinical
Trial
consent
|
see
http://ctep.cancer.gov/protocolDevelopment/docs/Informed_Consent_Template.docx
|
|
nih-grdr
|
NIH
Global
Rare
Disease
Patient
Registry
and
Data
Repository
consent
|
Global
Rare
Disease
Patient
Registry
and
Data
Repository
(GRDR)
consent
is
an
agreement
of
a
healthcare
consumer
to
permit
collection,
access,
use
and
disclosure
of
de-identified
rare
disease
information
and
collection
of
bio-specimens,
medical
information,
family
history
and
other
related
information
from
patients
to
permit
the
registry
collection
of
health
and
genetic
information,
and
specimens
for
pseudonymized
disclosure
for
research
purpose
of
use.
https://rarediseases.info.nih.gov/files/informed_consent_template.pdf
|
|
nih-527
|
NIH
Authorization
for
the
Release
of
Medical
Information
|
NIH
Authorization
for
the
Release
of
Medical
Information
is
a
patient’s
consent
for
the
National
Institutes
of
Health
Clinical
Center
to
release
medical
information
to
care
providers,
which
can
be
revoked.
Note:
Consent
Form
available
@
http://cc.nih.gov/participate/_pdf/NIH-527.pdf
|
|
ga4gh
|
Population
origins
and
ancestry
research
consent
|
Global
Alliance
for
Genomic
Health
Data
Sharing
Consent
Form
is
an
example
of
the
GA4GH
Population
origins
and
ancestry
research
consent
form.
Consenters
agree
to
permitting
a
specified
research
project
to
collect
ancestry
and
genetic
information
in
controlled-access
databases,
and
to
allow
other
researchers
to
use
deidentified
information
from
those
databases.
http://www.commonaccord.org/index.php?action=doc&file=Wx/org/genomicsandhealth/REWG/Demo/Roberta_Robinson_US
|
Terminology
.
Page
versions:
R4B
R4
|
Propose
a
change