600 Authorization for Disclosure of Protected Health Informa

DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration
AUTHORIZATION FOR DISCLOSURE OF PROTECTED
HEALTH INFORMATION PURSUANT TO HIPAA
INSTRUCTIONS: Complete Section I, II, and III of this form and return to Transportation Security
Administration (TSA) Chief Counsel at 6595 Springfield Center Drive Springfield, VA 20598-6002.
SECTION I – PATIENT DATA
1. Patient Name:
2. Date of Birth:
3. Social Security Number:
4. Patient Address:
SECTION II – RELEASE AUTHORIZATION
5. Information to be disclosed [45 C.F.R. § 164.508(c)(1)(i)]:

This includes information on the diagnosis or treatment of human immunodeficiency virus infection and
sexually transmitted diseases. This also includes information on the diagnosis and treatment of mental
illness and the use of alcohol, drugs, and tobacco, but excludes psychotherapy notes.
6. Person(s) or Organization(s) Authorized to make the disclosure [45 C.F.R. § 164.508(c)(1)(ii)]:
Any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy or
pharmacy benefit manager, medical facility, or other health care provider that has provided payment,
treatment, or services to me or on my behalf (“my Providers”).
7. Person or Organization to whom the disclosure may be made [45 C.F.R. § 164.508(c)(1)(iii)]:
Any person acting on behalf of the Chief Counsel or the Claims, Outreach and Debt Branch,
Transportation Security Administration, U.S. Department of Homeland Security, 6595 Springfield
Center Drive Springfield, VA 20598-6002.
8. Purpose for the use or disclosure of information [45 C.F.R. § 164.508(c)(1)(iv)]:
To permit TSA (a) to investigate and evaluate my administrative claim under the Federal Tort Claims
Act; (b) to engage fully and openly in discussions with my Providers to whatever extent necessary or
convenient properly to investigate my claim; and (c) to engage fully and openly in discussions with
any person or public or private agency concerning any matter relevant to my economic or health
background or history and/or health needs or conditions, to whatever extent necessary to obtain
information that will be used to evaluate and determine my claim.

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9. This authorization expires [45 C.F.R. § 164.508(c)(1)(v)]:
When TSA has finally adjudicated my claim or when I exercise my right under 28 U.S.C. § 2675(a) to
sue the United States upon my claim, whichever is earlier.
SECTION III – REVOCATION, PATIENT RIGHTS, & AUTHORIZATION FOR RELEASE
I understand that:
(a) I have the right to revoke this authorization at any time. My revocation must be in writing and
provided to the TSA Chief Counsel (TSA-2), Transportation Security Administration, 6595
Springfield Center Drive Springfield, VA 20598-6002. I am aware that a revocation is not
effective to the extent that any of my Providers or TSA have already relied on this authorization to
disclose information about me. 45 C.F.R. § 164.508(c)(2)(i).
(b) My Providers may not refuse to provide treatment or payment for health care services if I refuse
to sign this authorization. I further understand that if I refuse to sign this authorization, TSA may
be unable to obtain sufficient information to pay my claim. 45 C.F.R. § 164.508(c)(2)(ii).
(c) If I authorize my protected health information to be disclosed to someone who is not required to
comply with federal privacy protection regulations, then such information may be re-disclosed
and would no longer be protected. 45 C.F.R. § 164.508(c)(2)(iii).
I request and authorize my Providers to release the information described above to TSA without
restriction, and to discuss any of that information with TSA. A copy of this authorization is as valid
as the original.
10. Signature of Patient/Parent/Legal Representative
[45 C.F.R. § 164.508(c)(1)(vi)]:

11. Relationship to Patient
(if applicable):

12. Date:

In accordance with the Privacy Act of 1974, 5 U.S.C. § 552a(e)(3), this notice informs you of the
purpose of this form and how it will be used. Please read it carefully.
PRIVACY ACT STATEMENT: Authority: The Federal Tort Claims Act and implementing regulations ,
28 U.S.C. § 2672; 28 C.F.R. § 14.4. The Health Insurance Portability and Accountability Act of 1996 and
implementing regulations, Public Law 104-191, § 264 (110 Stat. 1936, 2033); 45 C.F.R. § 164.508.
Principal Purpose(s): To facilitate the investigation and adjustment of your federal tort claim by providing
the Transportation Security Administration with a means to request the use and/or disclosure of an
individual’s protected health information. Use(s): This form will be given to individuals and entities having
information relevant to your claim, as proof of your permission to release that information to TSA. The
information will be used to evaluate your federal tort claim, and may be disclosed to other parties who
may have knowledge of your claim or to consultants, to the extent necessary to obtain information that
will be used to evaluate, settle, refer, pay, or adjudicate your claim. Disclosure: Voluntary, but failure to
provide the requested information, including your Social Security number, may cause delay in processing
your claim or denial of payment.

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