When should health care providers use the standard consent form (DCH-3927) for release of specially-protected health information? When must a separate form be used?

Under the federal Health Insurance Portability and Accountability Act (HIPAA), health care providers may share most types of health information with other providers for purposes of payment, treatment, and health care operations. However, other federal and Michigan laws require that providers receive specific consent to share the following types of specially-protected health information: 

  • Behavioral or mental health services provided by the Michigan Department of Health and Human Services (MDHHS), a Community Mental Health Service Provider, or an entity under contract with the Department or a Community Mental Health Service Provider.
  • Referrals and/or treatment for a substance use disorder.
  • Communicable diseases such as sexually transmitted diseases and human immunodeficiency virus (HIV infection, Acquired Immune Deficiency Syndrome or AIDS Related Complex).

The The Department has created a standard form (DCH-3927) for sharing these types of information, as required under Public Act 129 of 2014.

Beyond the legal requirements for information-sharing described above, federal law gives added protection to information about individuals who have received services for domestic violence, sexual assault, and/or stalking from providers supported by certain types of federal funding. This Question provides more information about these extra protections. To meet the higher federal standards in these cases, service providers must use a separate form to obtain consent to share information, as follows:

  • If you receive funding under the federal Violence Against Women Act and/or the Family Violence Prevention and Services Act, and you have provided someone with services for domestic violence, sexual assault, or stalking, do not use the standard form created by the Department under Public Act 129 of 2014 (DCH-3927) to obtain that person's consent to release information about behavioral or mental health services, referrals and/or treatment for substance use disorders, or certain communicable diseases. Instead, use a separate form designed to address the heightened safety and privacy concerns that this person may have. The National Network to End Domestic Violence has a sample Client Limited Release of Information that you may adapt (available in English and Spanish). These Frequently Asked Questions provide you with guidance for using a separate form.
  • If you DO NOT receive funding under the federal Violence Against Women Act (VAWA) and/or the Family Violence Prevention and Services Act (FVPSA), and you have provided someone with services for domestic violence, sexual assault, or stalking, you should not use the standard form created by the Department under Public Act 129 of 2014 (DCH-3927) to obtain that person's consent to release information about behavioral or mental health services, referrals and/or treatment for substance use disorders, or certain communicable diseases. Although VAWA and FVPSA do not restrict you from using the standard form, it does not address the heightened safety and privacy concerns that this person may have. The National Network to End Domestic Violence has a sample Client Limited Release of Information that you may adapt (available in English and Spanish). These Frequently Asked Questions provide you with guidance for using a separate form.
  • If you are seeking health information about a person who has received services for domestic violence, sexual assault or stalking from another provider, the other provider should obtain the person's consent. This allows the other provider to consult with the person about possible heightened safety and privacy concerns. The other provider should use a separate form to obtain consent to share. You should not ask the person to complete the standard form created by the Department under Public Act 129 of 2014 (DCH-3927).