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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date: 4-29-2013

Volume:

X

Forms

Chapter:

A

Forms

Revised Date: 6-17-2019

Subchapter:

1

Forms

Issuance:

11.90

CP&P Form 11-90, HIPAA Authorization to Disclose Information

 

 

Click here to view or print the CP&P Form 11-90, HIPAA Authorization to Disclose Information.

 

Click here to view or print the CP&P Form 11-90(s), HIPAA Authorization to Disclose Information.

·                 The Spanish version of this form was translated on 6-17-2019.

 

 

WHEN TO USE IT

 

Use CP&P Form 11-90 or 11-90(s), HIPAA Authorization to Disclose Information, to obtain written authorization for any use or disclosure of protected health information that is not for treatment, payment, or health care operations.

 

DEFINITIONS

 

      "HIPAA" means the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, and regulations promulgated by the United States Department of Health and Human Services, 45 CFR Parts 160 and 164, Federal legislation enacted to establish national standards for privacy and security in the handling of health-related information.

 

      "Notice of Privacy Practices" ("NPP") means a form, developed by a covered entity, to advise its clients and others of their confidentiality rights under HIPAA. In New Jersey, the NPP is a Department of Children and Families form, approved by the Attorney General's Office for use by the Divisions and agencies which comprise DCF. (The Department assigned the NPP form number HIPAA 1.A.1.)

 

      "Covered Entity" means any health care provider, health plan, or health care clearinghouse that electronically transmits health information. The New Jersey Department of Children and Families is a covered entity. (Each Division, Commission or Office, as a component of the Department, is required to develop its own privacy policies and procedures in compliance. The Office of Education is an exception, and, as such, must be treated as outside the Department for HIPAA purposes.)

 

      "Protected Health Information" (PHI) means individually identifiable health information gathered or received by a covered entity. PHI includes oral, written and electronic health information about an individual that is stored or transmitted.

 

HOW TO USE IT

 

The assigned Worker/CP&P representative is responsible for providing the signatory with Form 11-90 or 11-90(s), HIPAA Authorization to Disclose Information, which includes the HIPAA Notice of Privacy Practices.

 

The Worker/CP&P representative should be prepared to answer questions about the authorization form, the privacy notice, CP&P handling of health information, the HIPAA law, etc. If the Worker has any questions he or she should seek input from a Supervisor or, if necessary, the local office Liaison to the Division's Privacy Officer.

 

The assigned Worker shall make sure that the form is fully completed and the signatory has provided their signature, date and telephone number on Form 11-90 or 11-90(s). Additionally, the assigned Worker shall make sure that the signatory has printed his or her name and signature on the Notice of Privacy Practices.

 

 

DISTRIBUTION

 

Original

_

Once signed, file in the health information section of the Child’s case record, or in the foster/adoptive home record or Other file maintained by CP&P, as applicable

Copy

_

Provide to the signer of CP&P Form 11-90 or 11-90(s)