STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY.
DEPARTMENT OF HEALTH CARE SERVICES. PRIVACY OFFICE. AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION. I,. ,
hereby authorize to. (Name of patient). (Name of person or facility which has information) release the …
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.
OCA Official Form No.: 960. AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA. [This form has been approved by the
New York State Department of Health]. Patient Name. Date of Birth. Social
Security Number. Patient Address. I, or my authorized representative, request that
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
Consent for Release of Information. Form Approved. OMB No. 0960-0566.
Instructions for Using this Form. Complete this form only if you want us to give information or records about you, a minor, or a legally incompetent adult, to an
individual or group (for example, a doctor or an insurance company). If you are
the natural or …
After you complete and sign the authorization form, return it to the address below:
Medicare BCC, Written … to release any and all of your personal health information. • Then proceed to question 2B. … your personal medical information
for any purpose that isn't set out in the privacy notice contained in the Medicare &
PRIVACY ACT INFORMATION: The execution of this form does not authorize the release of information other than that specifically described below. The … “routine
use” disclosure of the information as outlined in the Privacy Act system of records
notices identified as 24VA10P2 “Patient Medical Record – VA” and in.
This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or
other purposes as I may direct. 5. This authorization shall be in force and effect
until. (date or event), at which time this authorization expires. 6. I understand that I
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 or any other form that complies with HIPAA, the Texas Medical
NAME OF HEALTH PROVIDER TO RELEASE INFORMATION … INFORMATION
TO BE RELEASED (If the box is checked, you are authorizing the release of that
type of information). … I, or my authorized representative, authorize the use or
disclosure of my medical and/or billing information as I have described on this form.
May 10, 2016 … All information related to the claim for medical services or treatment described
below. Claim Number(s):. Date(s) of Service: Provider(s) Name: If “information
related to a sensitive” diagnosis is to be disclosed, the pertinent boxes must be
checked: Substance Abuse. HIV/AIDS. Genetic Testing. Mental Health …
OKLAHOMA STANDARD AUTHORIZATION TO USE OR SHARE PROTECTED
HEALTH INFORMATION (PHI). Patient Name: … □Substance Abuse Records □ Medical information compiled between___________ and ______. □Other: … I
have the right to withdraw permission for the release of my information. If I sign
CITY OF CINCINNATI. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. (Shaded areas denote required fields):. TO: (insert name of
benefits administrator or provider who you are requesting to release information):
The Department may, however, require that you authorize disclosure of your
health information if needed to make a determination about your eligibility for … I
Hereby Authorize: Date of Birth: Social Security Number: Zip Code: Street
Address: Name of Person/Agency: City: State: 2. To Release Information To: Zip
DISCLOSURE: Voluntary. Failure to sign the authorization form will result in the
non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or …
hereby voluntarily authorize the disclosure of information from my health record. II
. The information is to be disclosed by: NAME OF FACILITY. ADDRESS. CITY/
STATE … III. The purpose or need for this disclosure is: Further Medical Care.
Attorney. School. Research. Health Information Exchange (IHS/Other. ) Personal
your records under the same laws that apply to DSHS. DSHS cannot refuse you
benefits if you do not sign this form to allow disclosures to DSHS unless your authorization is needed to determine eligibility. For information on how DSHS health care components covered by HIPAA share protected health information
and your …
A health care provider may not use or disclose your protected health information (
“PHI”) without a valid authorization unless otherwise permitted under law. To authorize the disclosure of your PHI, please complete and sign the form below
and present it to your Health Care Provider, along with the applicable.