Medical Information Release Form



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Medical Information Release Form

PDF download:

VA Form 10-5345 – Veterans Affairs

www.va.gov

payment, enrollment or eligibility on signing the authorization. VA may disclose
the information that you put on the form as permitted by law. VHA may make a. “
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.

Authorization for Release of Protected Health Information

www.dhcs.ca.gov

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 …

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 Law and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996. (HIPAA), I understand that: 1. This authorization may …

Authorization for Release of Health Information (Including alcohol …

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 for Release of Health Information & Confidential HIV …

www.health.ny.gov

This form authorizes release of health information including HIVrelated
information. You may choose to release only your … in foster care or adoption;
official correctional, probation and parole staff; emergency or health care staff
who are accidentally exposed to your blood; or by special court order. Under
New York State …

Consent for Release of Information – Social Security

www.ssa.gov

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 adoptive parent or legal guardian,.

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 …

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 … After you complete and sign the
authorization form, return it to the address below: Medicare BCC … your personal
medical information for any purpose that isn't set out in the privacy notice
contained in …

Authorization to Disclose Protected Health Information

www.texasattorneygeneral.gov

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
 …

SOD Authorization to Release PHI Form FINAL 05.10.16- New …

ben.omb.delaware.gov

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 …

Authorization For Release of Medical Information – United States …

www.dol.gov

Programs of the U.S. Department of Labor any medical records or other
Information about (my) or (the deceased miner's) medical condition … (2) The
information in this form will be used to authorize medical treatment providers to
release information about the miner to the Department of Labor pertinent to the
black lung.

FOH Authorization for Medical Disclosure Form – HRSA

www.hrsa.gov

(The release of information about a patient who is treated or referred for treatment
for alcohol or drug abuse, or the medical results of such abuse, is governed by
the. Confidentiality of Alcohol and Drug Abuse Patient Record Regulations, 42
CFR Part 2). TO: Treating Medical Care Provider …

Authorization to Release Confidential Information – Texas …

www.dshs.texas.gov

I authorize the following health care provider, attorney, counselor, school, etc.: _.
(Individual … authorization; 2) this authorization will not affect treatment, payment,
enrollment, or eligibility for benefits; and 3) information disclosed as a … This form
( ) was read by me ( ) was read to me and I understand its meaning. All the …

form 4 – employee's authorization for release of medical records

orm.dc.gov

READ INSTRUCTIONS HERE AND ON THE REVERSE SIDE. For Help and
Information, call (202) 727-8600. IMPORTANT: Employees or the representative
of an employee must complete this form and submit it to the employee's
immediate supervisor within thirty (30) days of the injury, recurrence of disability,
or death. This.

Printing R:\\325\\FORMS\\01059.325

www.nd.gov

require that you authorize disclosure of your health information if needed to make
a determination about your eligibility for benefits or enrollment in a Department
health plan. AUTHORIZATION TO DISCLOSE INFORMATIONauthorization for
the disclosure of medical or other information is NOT sufficient for this purpose.

WORKER'S AUTHORIZATION FOR DISCLOSURE OF PROTECTED …

www2.nmcourts.gov

hereby authorize the health care provider (HCP) – (the name of HCP is optional
and not required for release of medical information) … authorized representatives
of the New Mexico Workers' Compensation Administration and its current medical
cost … records. This release may also be used to request a Form Letter to HCP.

client consent to fax confidential information – Florida Department of …

www.floridahealth.gov

You must give specific written authorization to release certain types of sensitive
medical information. The Florida Department of Health may fax confidential
medical information to a provider or receive faxed informationform does not
replace the client's consent to release confidential information form (DH 3111),
but should …

consent for release of information – Illinois.gov

www.illinois.gov

See reverse side of form for instructions. CFS 600-3. Rev 7/2015. CONSENT
FOR RELEASE OF INFORMATION. 1. I,. , hereby give consent to: 2. (Provider of
Information). (Address). 3. to release information concerning. B.D.. 4. to: (Address
). TYPE OF INFORMATION. (CIRCLE). 5. Medical (specify):. 6. Mental Health (
specify):.