C-4000, Confidential Nature of Medical Information

Revision 15-2; Effective June 1, 2015

Applicants/recipients requesting assistance on the basis of disability must complete a medical information release form.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets additional standards to protect the confidentiality of individually identifiable health information. Individually identifiable health information is information that identifies or could be used to identify an individual and that relates to the:

• past, present or future physical or mental health or condition of the individual;
• provision of health care to the individual; or
• past, present or future payment for the provision of health care to the individual.