HIPAA AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Authorization Pursuant to the Health Insurance Portability and Accountability Act of 1996 (45 C.F.R. §§ 164.502 and 164.508)
Execution Date: April 1, 2023
Section 1. Identity of the Individual Authorizing Disclosure
I, Jonathan Robert Caldwell, born March 14, 1956, currently residing at 418 East 72nd Street, Apt. 14A, New York, New York 10021, Social Security Number ending in XXX-XX-4781, hereby execute this Authorization for Disclosure of Protected Health Information (this "Authorization") pursuant to the Health Insurance Portability and Accountability Act of 1996, as amended, and the regulations promulgated thereunder at 45 C.F.R. Parts 160 and 164 (collectively, "HIPAA"), and any applicable state privacy and health information laws. I am referred to throughout this Authorization as the "Authorizing Party" or "Patient."
I execute this Authorization voluntarily and of my own free will. No person or entity has coerced, unduly influenced, or otherwise compelled me to execute this Authorization. I have not been offered, nor have I received, any consideration or inducement in exchange for executing this Authorization, other than the peace of mind that results from ensuring my designated family members and authorized representatives will have access to information necessary to participate meaningfully in decisions regarding my health care and personal welfare.
Section 2. Persons and Entities Authorized to Disclose Protected Health Information
This Authorization is directed to any and all health care providers, health plans, health care clearinghouses, hospitals, medical centers, clinics, physicians, surgeons, internists, specialists, pharmacies, laboratories, diagnostic imaging centers, rehabilitation facilities, nursing facilities, home health agencies, hospice providers, insurance companies, managed care organizations, and any other "covered entity" as that term is defined under HIPAA at 45 C.F.R. § 160.103, that maintains, possesses, controls, or otherwise has custody of protected health information ("PHI") of Jonathan R. Caldwell, whether such PHI is maintained in paper, electronic, or any other format.
Without limiting the generality of the foregoing, this Authorization shall apply to, and is specifically directed to, all physicians, specialists (including but not limited to cardiologists, oncologists, neurologists, orthopedic surgeons, gastroenterologists, endocrinologists, and urologists), mental health professionals (including psychiatrists, psychologists, licensed clinical social workers, and licensed mental health counselors), dentists, ophthalmologists, podiatrists, physical therapists, occupational therapists, and any other licensed or certified health care professional, as well as any hospital, ambulatory surgical center, outpatient clinic, urgent care facility, emergency department, long-term care facility, assisted living facility, or any other facility at which the Authorizing Party has received, is currently receiving, or may in the future receive treatment, diagnostic services, consultations, or any other health care services.
Each covered entity receiving a copy of this Authorization is hereby authorized and directed to disclose the PHI described in Section 4 below to the persons identified in Section 3 below, upon the request of any such person, without further authorization from the Authorizing Party, except as expressly limited herein or as otherwise required by applicable law.
Section 3. Persons Authorized to Receive Protected Health Information
The following named individuals are authorized to receive, inspect, obtain copies of, review, and discuss the Authorizing Party's PHI with any covered entity to which this Authorization is directed. Each authorized recipient is identified by full legal name, relationship to the Authorizing Party, date of birth, and current address for purposes of identification and verification by any covered entity.
3.1 Eleanor Victoria Caldwell
Relationship: Spouse
Date of Birth: September 22, 1958
Address: 418 East 72nd Street, Apt. 14A, New York, New York 10021
Eleanor Victoria Caldwell is the spouse of the Authorizing Party and serves as the primary health care agent under the Health Care Proxy of Jonathan R. Caldwell, dated April 1, 2023, and as the primary agent under the Durable General Power of Attorney of Jonathan R. Caldwell, dated April 1, 2023. She is authorized to receive, inspect, copy, and discuss any and all PHI of the Authorizing Party, without limitation, as described in Section 4 below.
3.2 Thomas Robert Caldwell
Relationship: Son
Date of Birth: June 7, 1985
Address: 55 Perry Street, Unit 3, New York, New York 10014
Thomas Robert Caldwell is the son of the Authorizing Party and serves as the successor agent under the Durable General Power of Attorney of Jonathan R. Caldwell, dated April 1, 2023. He is authorized to receive, inspect, copy, and discuss any and all PHI of the Authorizing Party, without limitation, as described in Section 4 below.
3.3 Katherine Claire Hartfield
Relationship: Daughter
Date of Birth: November 19, 1987
Address: 210 Briarcliff Lane, Greenwich, Connecticut 06830
Katherine Claire Hartfield is the daughter of the Authorizing Party and serves as the successor health care agent under the Health Care Proxy of Jonathan R. Caldwell, dated April 1, 2023. She is authorized to receive, inspect, copy, and discuss any and all PHI of the Authorizing Party, without limitation, as described in Section 4 below.
3.4 Olivia Grace Caldwell
Relationship: Daughter
Date of Birth: April 2, 1993
Address: 1240 North Dearborn Street, Apt. 807, Chicago, Illinois 60610
Olivia Grace Caldwell is the daughter of the Authorizing Party. She is authorized to receive, inspect, copy, and discuss any and all PHI of the Authorizing Party, without limitation, as described in Section 4 below.
Each of the foregoing authorized recipients may act independently and without the consent or knowledge of any other authorized recipient. Any covered entity may rely upon the request of any single authorized recipient and shall not be required to obtain the consent of, or provide notice to, any other authorized recipient before making a disclosure under this Authorization.
Section 4. Description of Protected Health Information to Be Disclosed
The Authorizing Party hereby authorizes the disclosure of any and all protected health information, without limitation as to time period, condition, or category, including but not limited to the following:
(a) Medical records, charts, clinical notes, and histories. All medical records in any form, including but not limited to physician's office records, hospital records, emergency department records, inpatient and outpatient records, consultation reports, clinical notes, progress notes, nursing notes, intake assessments, discharge summaries, and patient histories.
(b) Diagnoses, treatment plans, and prognosis information. All diagnostic information, including preliminary diagnoses, differential diagnoses, confirmed diagnoses, treatment plans, care plans, prognosis information, and any correspondence or communications relating to the foregoing.
(c) Laboratory, pathology, and radiology results. All laboratory test results, blood work, urinalysis, pathology reports, biopsy results, cytology reports, imaging results (including but not limited to X-rays, CT scans, MRI scans, PET scans, ultrasounds, mammograms, and bone density scans), and any interpretive reports related thereto.
(d) Prescription and medication records. All prescription records, medication lists, medication histories, pharmacy records, records of medication administration, and records relating to adverse drug reactions or drug interactions.
(e) Surgical and procedural records. All operative reports, anesthesia records, pre-operative evaluations, post-operative notes, procedural reports, and related surgical and procedural documentation.
(f) Mental health and psychiatric records. All mental health records, psychiatric evaluations, psychological testing results, therapy notes, psychotherapy notes, counseling records, and behavioral health records, to the extent that disclosure of such records is permitted by applicable state law, including but not limited to the New York Mental Hygiene Law. The Authorizing Party specifically and expressly consents to the disclosure of such records to the fullest extent permitted by law.
(g) Substance abuse treatment records. All records relating to the diagnosis, treatment, or referral for treatment of substance abuse or substance use disorders, to the extent that disclosure of such records is not prohibited by 42 C.F.R. Part 2 (Confidentiality of Substance Use Disorder Patient Records), and only with separate consent if required by federal or state law. To the extent that a separate written consent or authorization is required under 42 C.F.R. Part 2, the Authorizing Party hereby expresses his intent to provide such separate consent and directs his legal counsel to prepare any additional documentation necessary to effectuate such disclosure.
(h) Genetic testing and genetic information. All records of genetic testing, genetic counseling, and genetic information, including but not limited to results of any tests for hereditary conditions, chromosomal analyses, and any information derived from analysis of DNA, RNA, or protein sequences, to the extent permitted by the Genetic Information Nondiscrimination Act of 2008 ("GINA") and applicable state law.
(i) HIV/AIDS-related information. All HIV/AIDS-related information, including but not limited to HIV test results, HIV/AIDS diagnoses, and HIV/AIDS treatment records, to the extent permitted by applicable state law. The Authorizing Party acknowledges that New York Public Health Law Article 27-F imposes specific requirements and restrictions on the disclosure of confidential HIV-related information, and that a separate written consent may be required under such law. To the extent that this Authorization is insufficient to authorize disclosure of HIV-related information under New York Public Health Law Article 27-F, the Authorizing Party hereby expresses his intent to authorize such disclosure and directs his legal counsel to prepare any additional documentation necessary to comply with Article 27-F.
(j) Billing, insurance, and claims information. All billing records, insurance claims, explanation of benefits statements, payment records, health insurance policy information, and any communications with insurers, managed care organizations, or third-party administrators relating to the Authorizing Party's health care services.
(k) Communications between the Authorizing Party and any health care provider. All communications in any medium, including but not limited to letters, emails, secure messages, telephone logs, telehealth records, and patient portal communications, between the Authorizing Party and any health care provider.
The Authorizing Party specifically and expressly authorizes the disclosure of all categories of PHI described above, fully understanding that some categories — including without limitation HIV/AIDS-related information, mental health records, substance abuse treatment records, and genetic information — may be subject to heightened protections under federal and state law. It is the Authorizing Party's intent that this Authorization be construed as broadly as permitted by applicable law to facilitate the fullest possible disclosure of PHI to the authorized recipients identified in Section 3 above.
Section 5. Purpose of the Disclosure
The disclosure of PHI pursuant to this Authorization is authorized for the following purposes:
(a) Participation in health care decisions. To enable the authorized persons identified in Section 3 above to participate in health care decisions on behalf of the Authorizing Party, including but not limited to decisions relating to medical treatment, surgical procedures, diagnostic testing, medication management, rehabilitation, hospice care, and end-of-life care.
(b) Communication with health care providers. To facilitate communication between the authorized persons and the Authorizing Party's health care providers regarding the Authorizing Party's health status, diagnosis, treatment options, care coordination, and any other matters relating to the Authorizing Party's medical care and well-being.
(c) Exercise of authority under Health Care Proxy. To assist in the exercise of authority granted under the Health Care Proxy of Jonathan R. Caldwell, executed on April 1, 2023, which designates Eleanor Victoria Caldwell as the Authorizing Party's primary health care agent and Katherine Claire Hartfield as the Authorizing Party's successor health care agent. Access to the Authorizing Party's PHI is essential to the effective exercise of the health care agent's authority under the Health Care Proxy, and this Authorization is intended to ensure that the designated agents have complete and timely access to all information necessary to make informed health care decisions on the Authorizing Party's behalf.
(d) Exercise of authority under Durable General Power of Attorney. To assist in the exercise of authority granted under the Durable General Power of Attorney of Jonathan R. Caldwell, executed on April 1, 2023, which designates Eleanor Victoria Caldwell as the Authorizing Party's primary agent and Thomas Robert Caldwell as the Authorizing Party's successor agent. To the extent that the agent's duties under the Durable General Power of Attorney require access to the Authorizing Party's PHI — including but not limited to matters relating to health insurance, medical billing, coordination of benefits, and management of health-care-related expenditures — this Authorization is intended to ensure that such access is available.
(e) Any other purpose related to medical care and personal welfare. For any other purpose deemed necessary or appropriate by the Authorizing Party or his authorized representatives in connection with the Authorizing Party's medical care, health care planning, and personal welfare, including but not limited to long-term care planning, insurance matters, and disability determinations.
No Conditioning of Treatment, Payment, or Benefits. The Authorizing Party hereby affirms and acknowledges that this Authorization is not conditioned on any treatment, payment, enrollment in a health plan, or eligibility for benefits. No covered entity may require the execution of this Authorization as a condition of providing treatment to the Authorizing Party, processing any claim for payment, enrolling the Authorizing Party in any health plan, or determining the Authorizing Party's eligibility for any benefit.
Section 6. Effective Date, Expiration, and Duration
Effective Date. This Authorization shall become effective on April 1, 2023.
Expiration and Duration. This Authorization shall remain in full force and effect until revoked in writing by the Authorizing Party in accordance with Section 7 below, or until the death of the Authorizing Party, whichever first occurs; provided, however, that this Authorization shall survive the incapacity of the Authorizing Party and shall continue in full force and effect during any period of disability, incompetence, or incapacity of the Authorizing Party, whether temporary or permanent, partial or complete. The Authorizing Party specifically intends that this Authorization shall remain operative during any period in which the Authorizing Party is unable to make or communicate health care decisions, as it is during such periods that the need for disclosure of PHI to the authorized recipients is most critical.
No Fixed Expiration Date. This Authorization has no fixed expiration date. The Authorizing Party intends that this Authorization remain operative for the duration of his lifetime unless expressly revoked in accordance with the procedures set forth in Section 7 below. The Authorizing Party acknowledges that certain covered entities may, as a matter of internal policy, impose time limitations on the validity of HIPAA authorizations. In the event that a covered entity declines to honor this Authorization on the grounds that it lacks a fixed expiration date, the Authorizing Party directs the authorized recipients to contact Calderwood & Harkness LLP to obtain a re-executed or supplemental authorization, as necessary.
Section 7. Right to Revoke
The Authorizing Party has the right to revoke this Authorization at any time by providing written notice to the covered entity or entities from which disclosure is sought. Any such revocation must comply with the following requirements:
(a) Written notice required. Revocation of this Authorization must be in writing. Oral revocations shall not be effective.
(b) Signature required. The written revocation must be signed by the Authorizing Party. If the Authorizing Party is unable to sign due to physical incapacity, the revocation may be signed by a person authorized to act on the Authorizing Party's behalf under applicable law, provided that such person has legal authority to revoke this Authorization.
(c) Delivery to applicable covered entity. The written revocation must be delivered to the applicable covered entity that has received a copy of this Authorization and from which the Authorizing Party wishes to withdraw authorization for disclosure. The revocation shall be effective only upon receipt by the covered entity.
(d) No retroactive effect. Revocation of this Authorization shall not be effective with respect to any disclosures of PHI that were made by a covered entity in reliance on this Authorization prior to the covered entity's receipt of the written revocation. Any covered entity that has disclosed PHI in good faith reliance on this Authorization prior to receiving written revocation shall not be liable to the Authorizing Party or any other person for such disclosure.
(e) Notice to each covered entity. The Authorizing Party acknowledges that, because this Authorization is directed to all covered entities that maintain PHI of the Authorizing Party, a written revocation should be sent to each covered entity that has received a copy of this Authorization in order to be effective as to all such entities. A revocation directed to one covered entity shall not be effective as to any other covered entity unless and until such other covered entity also receives written notice of the revocation.
Section 8. Redisclosure Notice
NOTICE REGARDING REDISCLOSURE: The Authorizing Party acknowledges and understands that protected health information disclosed pursuant to this Authorization may be subject to redisclosure by the authorized recipients identified in Section 3 above, and that once PHI has been disclosed to such recipients, it may no longer be protected by HIPAA or the HIPAA Privacy Rule (45 C.F.R. Part 164, Subpart E), unless other applicable federal or state law provides continued protection. The Authorizing Party further acknowledges that the authorized recipients are not, solely by virtue of their receipt of PHI under this Authorization, "covered entities" or "business associates" within the meaning of HIPAA, and accordingly are not bound by the restrictions of the HIPAA Privacy Rule with respect to the use or further disclosure of the Authorizing Party's PHI, except to the extent that other applicable law imposes restrictions on such use or disclosure.
Notwithstanding the foregoing, the Authorizing Party requests that the authorized recipients treat the Authorizing Party's PHI with the utmost confidentiality and discretion, and that they refrain from disclosing such information to any person not authorized under this Authorization or not otherwise authorized by the Authorizing Party, except as may be necessary to carry out the purposes described in Section 5 above.
Section 9. Acknowledgment and Understanding
The Authorizing Party acknowledges, represents, and confirms each of the following:
(a) Understanding of Authorization. The Authorizing Party has carefully read this Authorization in its entirety and understands its contents, including the nature and scope of the PHI authorized to be disclosed, the identities of the persons authorized to receive such PHI, and the purposes for which disclosure is authorized.
(b) Right to refuse. The Authorizing Party has been informed of his right to refuse to sign this Authorization, and understands that he was under no obligation to execute this Authorization.
(c) No conditioning of treatment or benefits. The Authorizing Party understands that his treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon his signing this Authorization, in accordance with 45 C.F.R. § 164.508(b)(4).
(d) Receipt of copy. The Authorizing Party has received a copy of this signed Authorization for his personal records.
(e) Consultation with legal counsel. The Authorizing Party has had the opportunity to consult with legal counsel regarding this Authorization, including the attorneys at Calderwood & Harkness LLP, 375 Park Avenue, 42nd Floor, New York, New York 10152, and has had any and all questions regarding this Authorization answered to his satisfaction.
(f) Execution in connection with estate plan. The Authorizing Party acknowledges that this Authorization is being executed in connection with a comprehensive estate plan prepared by Calderwood & Harkness LLP (Matter No. 1034-00004) for the Authorizing Party, and is intended to be read and construed in conjunction with the Health Care Proxy of Jonathan R. Caldwell, the Durable General Power of Attorney of Jonathan R. Caldwell, and the other estate planning instruments executed by the Authorizing Party on or about April 1, 2023.
(g) Voluntary execution. The Authorizing Party is executing this Authorization voluntarily, without coercion, duress, or undue influence from any person or entity, and with full knowledge and understanding of its terms and consequences.
Section 10. Execution
10.1 Authorizing Party
AUTHORIZING PARTY:
By: ________
Name: Jonathan Robert Caldwell
Date: April 1, 2023
10.2 Witness Attestation
We, the undersigned witnesses, each being at least eighteen (18) years of age and of sound mind, hereby attest that we were present and witnessed the execution of this Authorization by Jonathan Robert Caldwell on the date set forth below. We observed the Authorizing Party sign this Authorization voluntarily, and he appeared to be of sound mind, under no constraint or undue influence, and fully aware of the nature and consequences of this Authorization.
Witness 1:
By: ________
Printed Name: Monica Reyes
Title: Associate, Calderwood & Harkness LLP
Address: 375 Park Avenue, 42nd Floor, New York, New York 10152
Date: April 1, 2023
Witness 2:
By: ________
Printed Name: Elliot Nguyen
Title: Associate, Calderwood & Harkness LLP
Address: 375 Park Avenue, 42nd Floor, New York, New York 10152
Date: April 1, 2023
Section 11. Notary Acknowledgment
ACKNOWLEDGMENT
STATE OF NEW YORK COUNTY OF NEW YORK
On this 1st day of April, 2023, before me, the undersigned, a Notary Public in and for the State of New York, personally appeared Jonathan Robert Caldwell, known to me (or proved to me on the basis of satisfactory evidence) to be the individual whose name is subscribed to the within instrument, and acknowledged to me that he executed the same in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of which the individual acted, executed the instrument.
I further certify that the said Jonathan Robert Caldwell appeared before me to be of sound mind and under no constraint or undue influence, and that he executed this Authorization voluntarily and of his own free will.
________________________________________
Notary Public, State of New York
Printed Name: ________
Commission Number: ________ My Commission Expires: ________
[NOTARIAL SEAL]
DOCUMENT INFORMATION
Prepared by: Calderwood & Harkness LLP, 375 Park Avenue, 42nd Floor, New York, New York 10152
Matter No.: 1034-00004
Billing Code: 78412-JRC
Note: This HIPAA Authorization is intended to be read and construed in conjunction with the Health Care Proxy and Durable General Power of Attorney of Jonathan R. Caldwell, each dated April 1, 2023, and the overall generational estate plan documents prepared by Calderwood & Harkness LLP for Jonathan R. Caldwell. In the event of any conflict between the provisions of this Authorization and the provisions of the Health Care Proxy or Durable General Power of Attorney, the provisions of the Health Care Proxy or Durable General Power of Attorney, as applicable, shall control with respect to the scope of authority granted to the designated agents thereunder, and this Authorization shall be construed to facilitate the broadest permissible access to PHI consistent with such authority.
© 2023 Calderwood & Harkness LLP. All rights reserved. This document is confidential and is intended solely for the use of Jonathan R. Caldwell and his designated legal counsel.