AUTHORIZATION TO DISCLOSE PROTECTED ... - …
[Pages:1]AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION (PHI)
PLEASE PRINT
Today's Date: Patient Name: Address: Phone Number: H-
Patient's SSN: Date of Birth:
W-
C-
Describe the information you approve disclosure of: All aspects of my healthcare as allowed to me under applicable law. Other:
To whom you approve disclosure:
Name: Phone #: City:
Address: State:
Relationship: Zip Code:
Name: Phone #: City:
Address: State:
Relationship: Zip Code:
Name: Phone #: City:
Address: State:
Relationship: Zip Code:
? I understand that I still have a right to access my PHI as allowed under applicable law. ? I understand that I may receive an accounting of disclosures as explained in AdventHealth
Medical Group's Notice of Patient Privacy Practices. ? I understand that my PHI may be disclosed for public policy purposes as stated in the
AdventHealth Medical Group's Notice of Patient Privacy Practices. ? I understand that AdventHealth Medical Group may terminate its agreement to use or disclose
any of my PHI at any time but only after I have received notice of such termination.
I understand that I may revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written authorization to the Health Management Department. I understand that my revocation will not apply to information already released in response to this authorization.
Signature of Patient or legal representative: Printed name of legal representative: Address and phone number of legal representative:
Relationship to Patient:
Practice Location: AdventHealth Medical Group
Form-69005, Rev. 06/19
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- authorization to disclose protected
- kansas medicare certified rural health clinics
- option 2 epn provider listing health insurance plans
- medical student clerkship elective catalog
- 2019 adventhealth cancer support groups
- spine surgery guidebook
- authorization to disclose protected health
- adventhealth medical group
Related searches
- payoff letter authorization to lender
- authorization to release medical records
- authorization to administer medication form
- authorization to release school records
- authorization to request school records
- authorization to close heloc
- dcf authorization to administer medication
- medical authorization to treat form
- authorization to request payoff
- authorization to close heloc letter
- authorization to release payoff form
- authorization to treat medical