Authorization for Release of Protected Health Information. I authorize the following entities to disclose my health information to Habitat for Humanity International, Inc., its affiliated companies, and their officers, directors, volunteers, agents, employees and their authorized representatives (for purposes of this paragraph, collectively "Habitat"): ACE American Insurance Company, its affiliated companies, and any authorized representatives ("Company"). My health information includes any and all information relating to my health which is in the possession of Company, including but not limited to medical and dental records, medical consultations, treatments, or surgeries; psychiatric or psychological care; use of drugs or alcohol; drug prescriptions; and communicable diseases, including HIV/AIDS. I understand the health information to be disclosed includes information protected under Federal and State law, including regarding mental health, substance abuse, developmental disabilities, infectious/communicable diseases, privileged communications and genetic information. I understand that the disclosure to Habitat is for the following purposes: eligibility confirmation; claim submission facilitation; claim inquiry and dispute resolution; fraud detection; and audit and quality control services. I understand that the signing of this Authorization is voluntary and is not required to receive benefits under any Company insurance policy. . I understand that I may request a copy of this Authorization. I agree that a photographic copy of this Authorization shall be as valid as the original. I understand that this Authorization is valid for the longer of 12 months or the duration of any claim for benefits under any Company insurance policy, but in no event longer than 24 months. I understand that I may revoke this Authorization at any time by providing written notification to the Company at CHUBB North American Claims c/o CHUBB A&H Claims, Xxx Xxxxxx Xxxxxx Xx, Xxxxxxxxxx, XX. 00000. Such revocation shall not have any effect on actions that the Company and/or Habitat took in reliance on the Authorization prior to each receiving notice of the revocation.
Authorization for Release of Protected Health Information. Each of the Player and his or her parent/legal guardian hereby authorizes any Provider who has protected health information regarding the Player to release such information to any third party, including, but not limited to, other medical providers and insurance companies, for purposes of treatment, payment and/or other health care operations.
Authorization for Release of Protected Health Information. I hereby authorize to disclose Protected Health Information (PHI) as deemed below. Patient: Requestor (if other than patient): Name Soc. Sec. # DOB Name Relationship Source of Legal Authority Name & Address of who to receive health records/information: Cholla Medical Group, Inc. 00000 X. 00xx Xxxxxx, Xxxxx 0 Phoenix, Arizona 00000-0000 Phone # 000-000-0000 Fax # 0-000-000-0000 ☐ I wish to have the following records copied and I will pick them up at your facility ☐ I request the facility copy the following records and fax/send them to the above address I request the release of all medical records created between Date and ☐ ☐ ☐ ☐ Legal Authority Request: I am the Patient noted above I am the Patient’s legal representative I am the Patient’s Power of Attorney I am the Patient’s legal Guardian Requestor’s Initials I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse) for use in medical treatment or consultation, billing or claims payment, or other purposes as I may direct. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization. If signing as a POA, please include a copy of documentation, as some providers will not release records without additional documentation. Signature__________________________________________________ Date______________________
Authorization for Release of Protected Health Information. I hereby authorize Xxxxx Xxxxxxx Wellness Center to release the following health information: ( ) My complete Wellness Center file ( ) Other: and forward it to the following person/facility: Person or Facility Address (street, city, state, zip code) Phone #: Email: The information is for the purpose of: This authorization is in effect until , when it expires. I understand that by signing this authorization: • I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. I understand that authorization is voluntary. • I understand the notice of the Privacies Practices provides instructions should I choose to revoke my authorization. • I understand that if the organization I have authorized to receive the information is not a health plan or health care provided, the released information may no longer be protected by federal privacy regulations. • I understand I have the right to receive a copy of this authorization. • I understand that I am signing this authorization voluntarily and that treatment, payment, or eligibility for my benefits will not be affected if I do not sign this authorization. I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT. SIGNATURE: DATE Wellness Center Member Guidelines Fitness Floor Guidelines
Authorization for Release of Protected Health Information. The Entity and my physician may release information from my medical records to any health care provider involved in my care and treatment or any appropriate governmental agency. The Entity and my physician may also release information from my medical records to any person or organization liable for all or part of my charges, such as my insurance carrier, any third-party payer, Medicare, and my employer’s worker’s compensation carrier. I acknowledge that upon the disclosure of Protected Health Information to an insurance company or other payer pursuant to this authorization, The Entity is no longer responsible for the confidentiality of any information known or possessed by the payer. I also understand that my records may be destroyed after 7 years.
Authorization for Release of Protected Health Information. Protected Health Information is generally shared by medical facilities and insurance sureties for the care and treatment of the Client. Authorization must be given by the Client (other than minor child) for the release of information to anyone other than medical facilities and your insurance company. Do you wish to authorize anyone, other than yourself, to have access to your medical information (i.e.; spouse, child, attorney)? If so, whom? Name: Relationship: EMAIL RELEASE: My signature here indicates agreement to the transmission of information through non-secured email. Client Date New Client Registration Patient Information Name Date of Birth Address City State Zip Marital Status Single Married Divorced Widowed SS# Sex M F Contact Information (for privacy purposes, please circle your preferred method of contact) Telephone (Daytime) Cell Phone Telephone (Evening) Email Primary Care Physician Name Phone # Address City State Zip Relationship with Physician (i.e. why do you see your PCP, are they aware of your nutrition needs, when was your last appt, etc.) Psychotherapist / Counselor Name Phone # Address City State Zip Relationship with Therapist (i.e. how long have you been seeing them, how often do you see them, etc.)
Authorization for Release of Protected Health Information. A Health Insurance Portability and Accountability Act compliant authorization signed by the client or client’s legal representative, authorizing DBH to release the client’s information to a designated recipient. This form must be completed thoroughly with specified records to be shared, a designated time frame and expiration date, as well as a signature by the DBH client or his/her legal representative. If the form is signed by a legal representative, proof from the court system designating legal representation must accompany the request.
