A valid authorization for use or disclosures not permitted will contain the following elements found on the CHS Authorization for Use and Disclosure of PHI:

1. A description of the information to be used or disclosed that is specific and meaningful;
2. The name or other specific identification of the person who is authorized to make the requested use or disclosure;
3. The name or other identification of the person to whom CHS may make the disclosure or use;
4. A description of each purpose of the requested use or disclosure.  It is permitted for the statement, “at the request of the individual” when the individual initiates the authorization and does not choose to provide a statement of the purpose;
5. An expiration date or event that relates to the individual or the purpose of the disclosure. 
6. Signature of the individual and date.  If the authorization is signed by a personal representative, a description of that authority to act must be provided.

In addition, the CHS Authorization contains the following statements:

1. The individual has the right to revoke the authorization in writing;
2. Reference to the CHS Notice of Privacy Practices for additional information
3. That CHS will not condition treatment on the basis of the authorization
4. The potential for information disclosed by the authorization to be subject to  re-disclosure by the recipient and no longer be protected by HIPAA.

CHS will provide the individual with a copy of the signed authorization.