Medical Information Disclosure Form



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Medical Information Disclosure Form

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Authorization to Disclose information to Social Security Administration

www.ssa.gov

PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW
**. I voluntarily authorize and request disclosure (including paper, oral, and
electronic interchange): OF WHAT All my medical records; also education
records and other information related to my ability to perform tasks. This includes
specific …

HIPAA Form – New York State Unified Court System

www.nycourts.gov

I, or my authorized representative, request that health information regarding my
care and treatment be released as set forth on this form: In accordance with New
York State … (HIPAA), I understand that: 1. This authorization may include
disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL
HEALTH.

Authorization for Release of Protected Health Information – DHCS …

www.dhcs.ca.gov

DEPARTMENT OF HEALTH CARE SERVICES. PRIVACY OFFICE … I authorize
the use or disclosure of my individually identifiable health information as
described above for the purpose listed. … to this authorization may not further use
or disclose the medical information unless another authorization is obtained from
me or …

Authorization to Disclose Protected Health Information

www.texasattorneygeneral.gov

legally authorized representative to electronically disclose that indi- vidual's
protected health information. Authorization is not required for disclosures related
to treatment, payment, health care operations, performing certain insurance
functions, or as may be otherwise au- thorized by law. Covered entities may use
this form …

Authorization for Release of Health Information & Confidential HIV …

www.health.ny.gov

This form authorizes release of health information including HIVrelated
information. You may … Your information may be protected from disclosure by
federal privacy law and state law. Confidential … The law protects you from
HIVrelated discrimination in housing, employment, health care and other services
. For more …

Authorization for Release of Health Information – New York State …

www.health.ny.gov

I, or my authorized representative, request that health information regarding my
care and treatment be released as set forth on this form. I understand that: 1. This
authorization may include disclosure of information relating to ALCOHOL and
DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL.

AUTHORIZATION TO DISCLOSE INFORMATION TO THE …

www.vba.va.gov

NOTE – PLEASE READ THE ENTIRE FORM (both pages) BEFORE SIGNING IN
ITEM 11 BELOW. NOTE: This general and special authorization to disclose was
developed to comply with the provisions regarding disclosure of medical and
other information under. P.L. 104-191 ("HIPAA"); 45 C.F.R. parts 160 and 164; …

Health Information Authorization Form – HRSA

www.hrsa.gov

Only information (e.g. medical records) related to (specify injury or cause of death
)______ … for certain medical research purposes when consistent with the
purposes for which the CICP was forme identified data … Consenting to this
authorization of disclosure of records is voluntary and health provider(s) shall not
co.

Authorization to Disclose Personal Health Information – Medicare.gov

www.medicare.gov

This form is used to advise Medicare of the person or persons you have chosen
to have access to your personal health … “1-800-MEDICARE Authorization to
Disclose Personal Health InformationForm. Please use this … your personal
medical information for any purpose that isn't set out in the privacy notice
contained in …

Authorization to Release or Obtain Health Information HIPAA 402P

dhh.louisiana.gov

Further Medical Care. ❒ Personal. ❒ Legal Investigation or Action. ❒ Changing
Physicians. ❒ Research related treatment. ❒ Creating health information for
disclosure to a third party. ❒ Other: (Specify) … I authorize a copy. (including
electronic or faxed copy) of this form for the disclosure of the information
described above.

Privacy Waiver Authorizing Disclosure to a Third Party – ICE

www.ice.gov

Use this form to authorize the U.S. Department of Homeland Security (“DHS”) to
disclose information and/or records about you to a third party. Taking this action
is entirely voluntary; you are under no obligation to consent to the release of your
information to any third party. Authority: Privacy Act of 1974 (5 U.S.C. § 552a); …

Questionnaire for National Security Positions – OPM

www.opm.gov

Your Social Security Number (SSN) is needed to identify records unique to you.
Although disclosure of your SSN is not mandatory, failure to disclose your SSN
may prevent or delay the processing of your background investigation. The
authority for soliciting and verifying your SSN is Executive. Order 9397. This form
will be …

Authorization to Disclose Information – Mass.gov

www.mass.gov

Section II (B), your permission will not be valid, and we will not be able to share
your information with the person(s) or organization you listed on this form.
SECTION I. I,. , give my permission … minor child, a court appointed guardian or
executor, a custodial parent, or a health care agent), please: Print the name of the
person …

NYCHHC HIPAA Authorization to Disclose Health Information

www.nyc.gov

I, or my authorized representative, authorize the use or disclosure of my medical
and/or billing information as I have described on this form. I understand that my
medical and/or billing information could be re-disclosed and no longer protected
by federal health information privacy regulations if the recipient(s) described on …

Authorization for Disclosure of Information – IRS Return … – IRS.gov

www.irs.gov

The use of this form is voluntary. This form is used by FOH to obtain medical
certification related to your Reasonable Accommodation request from your health
care provider. By providing the information requested on this form, FOH will be
able to obtain information from your medical provider. FOH will use this medical …

Authorization to Use and/or Disclose Educational and … – Oregon.gov

www.oregon.gov

By marking the boxes below, I authorize the use/disclosure of the following
specific medical and/or educational records: ❑ Physician's Eligibility Statement …
I have the right to request a copy of this form after I sign it as well as inspect or
copy any information to be used and/or disclosed under this authorization (if
allowed by …

Joint Guidance on the Application of the FERPA and HIPAA – U.S. …

www2.ed.gov

Where the HIPAA Privacy Rule applies, does it allow a health care provider to
disclose protected health information (PHI) … Does FERPA permit a
postsecondary institution to disclose a student's treatment records or education
records to …. information in electronic form in connection with covered
transactions. See 45 CFR …

authorization for release of information/records – Maine.gov

www.maine.gov

to release, disclose, and furnish all individually identifiable medical and health
care information, regarding the following patient, including but not limited to any
and all medical/treatment records created by other … that this authorization is as
valid whether in the original, a photocopy, a facsimile, or in electronic form. DATE
:.