Authorization for Release of Information. DUE TO THE FDCPA, WE ARE NOT ALLOWED TO RELEASE ANY INFORMATION REGARDING YOUR ACCOUNT WITHOUT WRITTEN CONSENT. THE ONLY PERSON ALLOWED TO RECEIVE INFORMATION OR MAKE CHANGES TO ANY ACCOUNT WITH VERMILION PARISH WATERWORKS DISTRICT NO. 1, IS THE INDIVIDUAL NAMED ON ACCOUNT AS WATER USER OR LEGAL SPOUSE IF NAMED ON WATER USER AGREEMENT AS SUCH. BY SIGNING THE RELEASE FORM BELOW YOU ARE GIVING OUR OFFICE PERMISSION TO DISCUSS YOUR ACCOUNT WITH ONLY THE INDIVIDUAL OR INDIVIDUALS LISTED. THIS RELEASE FORM SHALL REMAIN IN EFFECT AS LONG AS YOUR ACCOUNT IS ACTIVE. IF AT ANY TIME YOUR ACCOUNT SHOULD BECOME INACTIVE A NEW RELEASE WILL HAVE TO BE COMPLETED FOR THE NEW ACCOUNT. IF AT ANYTIME YOU SHOULD CHOOSE TO TERMINATE OF CHANGE THIS AUTHORIZATION, WE REQUIRE WRITTEN NOTICE STATING YOUR INTENTIONS. I, (FIRST) (MI) (LAST) HEREBY AUTHORIZE VERMILION PARISH WATERWORKS DISTRICT NO. 1 TO DISCUSS WITH AND/OR RELEASE INFORMATION WITH REGARDS TO MY ACCOUNT AT THE FOLLOWING ADDRESS TO THE FOLLOWING:
Authorization for Release of Information. The institution rendering services is hereby authorized to furnish and release, in accordance with facility policy, such professional and clinical information as may be necessary for the completion of my medical claims by valid third-party agents or agencies from the medical records compiled during treatment. The facility rendering treatment is hereby released from all legal liability that may arise from the release of said information. I also authorize the release of any and all medical records from other facilities requested by the above entity, as may be required for completion of the therapist's chart review, assessments, and evaluations. After 90 days, a new signed Release of Information is required. Financial Responsibility We participate in most major health insurance plans. As a courtesy to our patients, we will submit insurance claims to your carrier and verify your plan benefits. We expect you to: • Be responsible for understanding the details of your insurance coverage, including requirements for pre- authorization, annual deductible, co-pay, or co-insurance amounts, and visit or dollar limitations for physical therapy services. • Provide us with a current copy of your insurance card(s) and notify us of any changes in your insurance coverage. If we do not have current insurance billing information, we will expect full payment at the time of service. Our Business Office team will verify coverage with your insurance carrier; this is, however, no guarantee of benefit. Some plans have a set co-pay per visit; some require you pay a co-insurance percentage, after satisfying your plan- year medical deductible. We expect you to: • Be responsible for any charges not paid by your insurance company within 60 days of our filing. • If your plan has a co-pay per visit, payment is due at time of service, per our contract with your insurance. • If your plan has a medical deductible which has not yet been satisfied, a minimum deposit of $100 is due at the time of service. • If your plan has a co-insurance per visit, an estimated amount will be determined, and payment is encouraged at time of service which applies as a credit to your account. This prevents you receiving a large billing once the insurance has completed processing several claims. We mail patient statements each month after insurance has processed any claims. • If any durable medical equipment (DME) is recommended by your provider, we do not bill your insurance for these items. If you choose to purc...
Authorization for Release of Information. I hereby authorize AASL to obtain information from and release information (i.e. records, reports, treatments, evaluations) to the following individuals and organizations (i.e. physicians, case managers, teachers, other therapists etc.). This will be in effect for the duration of AASL providing services unless otherwise revoked in writing.
Authorization for Release of Information. Resident acknowledges that in order to facilitate Resident's use of the locker system, Landlord will be providing to the third-party vendor who administers the locker program Resident’s personal information and Resident hereby consent to the same.
Authorization for Release of Information. My child is a client of Pure Pediatric Therapy, Inc., and I authorize the release of information and relative documentation regarding my child’s participation in therapy. I understand I will be informed of the content of any conversations and release of medical information that is exchanged. Child’s Name Date of Birth I authorize the release of this information to the following professionals: Pediatrician/Physician: Additional Professionals: Parent/Caregiver Signature Date Therapist Name Date Acknowledgement of Privacy Practices Patient’s Full Name: I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain rights to privacy regarding my protected health information. I understand this information will be used to:
Authorization for Release of Information. My child is a client of Pure Pediatric Therapy, Inc., and I authorize the release of information and relative documentation regarding my child’s participation in therapy. I understand I will be informed of the content of any conversations and release of medical information that is exchanged. Child’s Name Date of Birth I authorize the release of this information to the following professionals: Name and contact information of Medical Professionals/Educational Staff/Therapists/etc: Name Contact Info Name Contact Info Name Contact Info Parent/Caregiver Signature Date Parent Consent As this child’s parent or guardian, I give my consent and permission for my child to receive medical and wellness services by Pure Pediatric Therapy therapists and staff to include evaluations, procedures and or treatments prescribed by my physician and my child’s therapist as is necessary in their judgment. Pure Pediatric Therapy has my permission to photograph and/or videotape my child to use in evaluation or treatment. Pure Pediatric Therapy has my permission to use my child’s photograph/video and description of such media publically to promote the clinic. I understand that the images/videos/description may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
Authorization for Release of Information. In-State
Authorization for Release of Information. In-State for the licensing applicant and all household members age 16 and older
Authorization for Release of Information. E. The Lessor must ensure the LCO (or the LCO's designated representative) has all of the requested documentation to ensure the completion of the background investigation.
Authorization for Release of Information. I authorize Earn to Learn or its representatives to release any and all information, records, or documents deemed by the Earn to Learn Program to be necessary including the status of any application for admissions to any educational and or training institution, matriculation at or in such institution, and university financial aid information. All individuals or entities presented with authorization by the Earn to Learn Program or its representatives are expressly authorized to permit the Earn to Learn Program or its representatives to obtain copies of any and all documents or records they request. Initial
