Release of Information Form Sample Clauses

Release of Information Form. Since the treatment provider letter is maintained as part of your medical record in CAPS and/or UHS, a limited Release of Information Form is required in order for the Xxxxx clinicians to participate fully in the clearance committee. Signing the release allows Xxxxx’x clinicians to share some information included in the support letter provided to us. The form is Xxxxx'x standard release and has been pre-completed to indicate that you give the CAPS and/or UHS staff who review your letter permission to share relevant information with the committee. This release does not apply to any information aside from the letter, and it does not give permission to share the contents of the letter with anyone outside of the committee. The form can be found in the medical leave section of the Student Support Services website and will also be provided to you as part of reminders about the clearance process. CLEARANCE REVIEW PROCESS
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Release of Information Form. Since the treatment provider letter is maintained as part of your medical record in CAPS and/or UHS, a limited release of information form is required in order for the Brown clinicians to participate fully in the clearance committee. Signing the release allows Xxxxx’x clinicians to share some information included in the support letter provided to us. The form is Xxxxx'x standard release and has been pre-completed to indicate that you give the CAPS and/or UHS staff who review your letter permission to share relevant information with the committee. This release does not apply to any 1 See xxxxx://xxx.xxxxx.xxx/offices/student-support/meeting-xxxx/course-load-reductions. information aside from the letter, and it does not give permission to share the contents of the letter with anyone outside of the committee. The form can be found in the medical leave section of the Student Support Services website and will also be provided to you as part of reminders about the clearance process. CAS Documents
Release of Information Form giving permission to appropriate eSchool staff to discuss progress and updates with the student’s referring health care provider.
Release of Information Form. If applicable, the provider shall ensure that the client signs a Release of Information form (Attachment IX) that authorizes the release of DHS SAVE data to ESS, RS, and the provider, and that explains when social security number disclosure is mandatory and when the disclosure is voluntary.
Release of Information Form. If you wish to have a family member, power of attorney, etc. discuss any aspect of your medical care with our providers and staff, please sign below and indicate to whom we may speak. □Check this box if you decline authorizing permission to others.
Release of Information Form. I, hereby authorize Xxxxx Xxxxxx, Ph.D. to release information regarding my / my child’s case to, Name Address Information to be released: Psychoeducational Report/ Assessment Results Information regarding therapy sessions Other

Related to Release of Information Form

  • Release of Information Except as required by law, no public release of any information, or confirmation or denial of same, with respect to this Contract or the subject matter hereof, will be made by SELLER or its subcontractors without the prior written approval of LOCKHEED XXXXXX. SELLER shall not use "Lockheed Xxxxxx," "Lockheed Xxxxxx Corporation," or any other trademark or logo owned by LOCKHEED XXXXXX, in whatever shape or form, without the prior written consent of LOCKHEED XXXXXX.

  • PUBLIC RELEASE OF INFORMATION Company does not endorse products or services. Accordingly, Xxxxxx agrees not to use Company’s name, the name Oak Ridge National Laboratory (ORNL), the name of any of its projects or programs, or identifying characteristics of any of these for advertising, marketing, or other promotional purposes, raising of capital, recommending investments, sale of securities, or in any way that implies endorsement by UT-Battelle, ORNL, or DOE. Any media releases concerning this Agreement are prohibited without written consent of the Subcontract Administrator.

  • CREDIT REVIEW AND RELEASE OF INFORMATION You authorize the Credit Union to investigate your credit standing when opening or reviewing your account. You authorize the Credit Union to disclose information regarding your account to credit bureaus and creditors who inquire about your credit standing. If your account is eligible for emergency cash and/or emergency card replacement services, and you request such services, you agree that we may provide personal information about you and your account that is necessary to provide you with the requested service(s).

  • Use of Information The Agent may not use any information gained in connection with this Agreement and the transactions contemplated by this Agreement, including due diligence, to advise any party with respect to transactions not expressly approved by the Company.

  • Exchange of Information Confidentiality Article VII Further Assurances and Additional Covenants; Article VIII Termination; and Article X Miscellaneous, other than Section 10.3

  • Disclosure of Information; Confidentiality The Agents and each Lender agree to hold any confidential information which it may receive from the Borrower pursuant to this Agreement in confidence, except for disclosure to (i) legal counsel, accountants, and other professional advisors, on a need-to-know basis, (ii) regulatory officials, (iii) as required by law or legal process (including by subpoena) or in connection with any legal proceeding, and (iv) another financial institution in connection with a disposition or proposed disposition of any of its interests hereunder or under any Loan Document, upon execution by such institution of an agreement to keep such information confidential to the extent described in this Section 12.8(g). The Agents and Lenders agree that the breach of this Section 12.8(g), including the disclosure of any confidential information received from the Borrower pursuant to this Agreement, shall constitute a material breach of this Agreement. Notwithstanding (ii) and (iii) above, in the event that any such Person is requested pursuant to, or required by, Applicable Law or Governmental Authority to disclose any such information, such Person will provide the Borrower with prompt notice of such request or requirement, unless prohibited by law or regulation, in order to enable the Borrower to seek an appropriate protective order or other remedy, or to consult with such Person with respect to the Borrower's taking steps to resist or narrow the scope of such request or legal process. If, in such event, the Borrower has not provided such Person with a protective order or other remedy in sufficient time, with such Person acting in good faith and otherwise in its sole discretion, for such Person to avoid unlawful nondisclosure of such information, such Person may disclose such information pursuant to such Applicable Law or Governmental Authority, as the case may be, without any recourse or remedy against such Person by the Borrower or any Affiliate of the Borrower, which the Borrower hereby expressly waives.

  • Furnishing of Information; Public Information (a) Until the earliest of the time that (i) no Purchaser owns Securities or (ii) the Warrants have expired, the Company covenants to maintain the registration of the Common Stock under Section 12(b) or 12(g) of the Exchange Act and to timely file (or obtain extensions in respect thereof and file within the applicable grace period) all reports required to be filed by the Company after the date hereof pursuant to the Exchange Act even if the Company is not then subject to the reporting requirements of the Exchange Act.

  • Confidentiality and Use of Information (a) Consultant shall hold in trust for the District, and shall not disclose to any person, any confidential information. Confidential information is information which is related to the District's research, development, trade secrets and business affairs, but does not include information which is generally known or easily ascertainable by nonparties through available public documentation.

  • Non-Disclosure of Information In the event Executive's employment has been terminated pursuant to either Section 6(b) or Section 6(c) hereof, Executive agrees that, during the Restricted Period, Executive will not use or disclose any Proprietary Information of the Company for the Executive's own purposes or for the benefit of any entity engaged in Competitive Business Activities. As used herein, the term "Proprietary Information" shall mean trade secrets or confidential proprietary information of the Company which are material to the conduct of the business of the Company. No information can be considered Proprietary Information unless the same is a unique process or method material to the conduct of Company's Business, or is a customer list or similar list of persons engaged in business activities with Company, or if the same is otherwise in the public domain or is required to be disclosed by order of any court or by reason of any statute, law, rule, regulation, ordinance or other governmental requirement. Executive further agrees that in the event his employment is terminated pursuant to Sections 6(b) or 6(c) above, all Documents in his possession at the time of his termination shall be returned to the Company at the Company's principal place of business.

  • Nondisclosure of Information To the extent necessary for the execution of this Agreement or to satisfy the requirements for disclosure to participants or to meet the requirements of Sections 8 and 9, the Advisor shall keep in strict confidence all information about the financial affairs of the Subaccount. The Advisor may include information about the Subaccount in aggregate information provided by the Advisor as long as the information is not set out separately or in any other manner that would enable a third party to determine the financial affairs of the Subaccount.

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