USE AND DISCLOSE YOUR HEALTH INFORMATION Sample Clauses

USE AND DISCLOSE YOUR HEALTH INFORMATION. This CNS Combined Services Agreement is an agreement between the Client/Person being evaluated and the Client’s representative (Parent(s), Legal Guardian and Children’s Neuropsychological Services LLC (CNS). When we use the word “you” below it will mean your child, relative, or other person being provided services by CNS. When CNS examines, diagnoses, treats, or refers you CNS will be collecting what the law calls Protected Health Information (PHI) about you. CNS needs to use this information here to decide on what treatment is best for you and to provide treatment to you. CNS may also share this information with others who provide treatment to you or need it to arrange payment for your treatment or for other business or government functions. By signing this form you are agreeing that you have read and understand the CNS Combined Services Agreement you are agreeing to let CNS use your information here and send it to others in accordance with our written policies. Please make sure you have read and understand our Privacy Policies above before signing this Consent form. If you do not sign this consent form agreeing to what is in our Notice of Privacy Policies (NPP), CNS cannot treat you. In the future CNS may change how we use and share your information and so may change our Notice of Privacy Policies. If we do change it, you can get a copy from our website: xxx.xxxxxxxxxxxxxxxxxxx.xxx or by calling us at 000-000-0000, or from our privacy officer, Xx. Xxxxxxx Xxxxx. If you are concerned about some of your information, you have the right to ask CNS not to use or share some of your information for treatment, payment, or administrative purposes. You will have to tell CNS what you want in writing. Although CNS will try to respect your wishes, we are not required to agree to these limitations. However, if we do agree, CNS promises to comply with your wish. After you have signed this consent, you have the right to revoke it (by writing a letter telling CNS you no longer consent) and we will comply with your wishes about using or sharing your information from that time on, but we may already have used or shared some of your information and cannot change that. Please print and keep a copy of this agreement for your records. Name of Client/Person being evaluated: Date of Birth of Client/Person being evaluated: Name of Client's representative (Parent/Legal Guardian): * Signature of Client's representative (Parent/Legal Guardian): * Date of Signature:
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USE AND DISCLOSE YOUR HEALTH INFORMATION. This form is an agreement between you, and me, Xxxxxxx Xxxxxx, Ph.D. When I use the words “you” and “your” below, this can mean you, your child, your relative, or some other person if you have written his or her name here: . When I examine, test, diagnose, treat, or refer you, I will be collecting what the law calls “protected health information” (PHI) about you. I need to use this information to decide on what treatment is best for you and to provide treatment to you. I may also share this information with your insurance company to help provide treatment for you. By signing this form, you are agreeing to let me use your PHI and to send it to your insurance company for the purposes described above. Your signature below acknowledges that you have read or heard my notice of privacy practices, which explains in more detail what your rights are and how I can use and share your information. If you do not sign this form agreeing to my privacy practices, I cannot treat you (or your child if your child is the patient). In the future, I may change how I use and share your information, and so I may change my notice of privacy practices. If I do change it, I will give you the revised practices. If you are concerned about your PHI, you have the right to ask me not to use or share some of it for treatment, payment, or administrative purposes. Please provide this information in writing. Although I will try to respect your wishes, I am not required to accept these limitations. After you have signed this consent, you have the right to revoke it by written request. Signature of client or his/her personal representative Date
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USE AND DISCLOSE YOUR HEALTH INFORMATION. This form is an agreement between you, _____ , and Xxxxxxx Xxxxxxxxx, Psy.D. &
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Related to USE AND DISCLOSE YOUR HEALTH INFORMATION

  • Use and Disclosure of Protected Health Information The Business Associate must not use or further disclose protected health information other than as permitted or required by the Contract or as required by law. The Business Associate must not use or further disclose protected health information in a manner that would violate the requirements of HIPAA Regulations.

  • Use and Disclosure of Confidential Information Notwithstanding anything to the contrary contained in this Agreement, and in addition to and not in lieu of other provisions in this Agreement:

  • Protected Health Information “Protected Health Information” shall have the same meaning as the term “protected health information” in Section 160.103 and is limited to the information created or received by Contractor from or on behalf of County.

  • Health Information Subject to all applicable privacy laws, the member irrevocably authorises any doctor or other person who may have, or may acquire, any information concerning their health to disclose such information to Specialty Emergency Services, and that this authority shall remain in force for a period of not less than 12 (twelve) months following the expiry date of this Membership Agreement.

  • Permitted Uses and Disclosures by Business Associate 1. Business Associate may only use or disclose protected health information as necessary to perform the services as outlined in the underlying agreement.

  • Permitted Uses and Disclosures of Phi by Business Associate Except as otherwise indicated in this Agreement, Business Associate may use or disclose PHI only to perform functions, activities or services specified in this Agreement on behalf of DHCS, provided that such use or disclosure would not violate HIPAA if done by DHCS.

  • Permitted Uses and Disclosure by Business Associate (1) General Use and Disclosure Provisions Except as otherwise limited in this Section of the Contract, Business Associate may use or disclose PHI to perform functions, activities, or services for, or on behalf of, Covered Entity as specified in this Contract, provided that such use or disclosure would not violate the HIPAA Standards if done by Covered Entity or the minimum necessary policies and procedures of the Covered Entity.

  • Permitted Use and Disclosures Each Party hereto may use or disclose Information disclosed to it by the other Party to the extent such use or disclosure: (i) is reasonably necessary in complying with Applicable Laws or otherwise submitting information to tax or other governmental authorities, (ii) is provided by the receiving Party to Third Parties, on a strictly as-needed basis, for consulting services, conducting Preclinical or Clinical Development, CMC/Process Development, Manufacturing, external testing, market research, or otherwise exercising its rights or performing its obligations hereunder; provided, that such Third Parties are obligated to maintain the confidentiality of such other Party’s Information as set forth herein for the benefit of such other Party for a period of at least the term of the agreement with such Third Party and for a period of *** thereafter; (iii) is included in submissions by the receiving Party to Governmental Authorities to facilitate the issuance of approvals for NDAs and NDA Equivalents for the Product, provided that reasonable measures shall be taken to assure confidential treatment of such Information; or (iv) is to Third Parties in connection with a receiving Party’s efforts to secure financing or enter into strategic partnerships, provided such Information is disclosed only on a need-to-know basis and under confidentiality provisions at least as stringent as those in this Agreement. Additionally, Bayer may disclose to Mitsui any Information received from Licensee hereunder; provided, that such disclosure is reasonably considered by Bayer to be necessary to comply with the terms and conditions of the Patent License Agreement; and further provided, that Mitsui is obligated to maintain the confidentiality of Licensee’s Information as set forth herein for the benefit of Licensee. Notwithstanding the foregoing, if a receiving Party is required to make any such disclosure of the disclosing Party’s confidential Information, other than pursuant to a confidentiality agreement, the receiving Party will give reasonable advance notice to the disclosing Party of such disclosure and, save to the extent inappropriate in the case of patent applications, will use its reasonable efforts to secure confidential treatment of such Information prior to its disclosure (whether through protective orders or otherwise).

  • Use and Disclosure of PHI Business Associate is limited to the following permitted and required uses or disclosures of PHI:

  • Confidentiality of Health Information (a) A Nurse shall not be required to provide her or his manager/supervisor specific information regarding the nature of her or his illness or injury during a period of absence. However, the Employer may require the Nurse to provide such information to persons responsible for occupational health.

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