AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Sample Clauses

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize Motivate to release information required in the processing of application for financial coverage for services rendered. This authorization provides that my physician or my physician’s staff may release objective clinical information related to my diagnoses and treatment, which may be requested by my insurance company or its designated agent. This authorization also includes any medical records containing information related to HIV (Aids) testing and/or psychiatric care rendered to me if such records are released to an insurance company writing Life, Accident or Health Insurance or a Non Profit Health Care Service Plan Corporation to evaluate my claims or its liability under such policies or contracts or coordination of benefits pursuant to such policy or contract provisions. The information obtained will be treated as privileged and confidential and will not be released to any person without my expressed or written consent. Correspondence and test results will only be released to physicians involved in my care.
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize any physician or other healthcare professional, hospital or healthcare-related facility, pharmacy, medical service provider, employer, benefit plan administrator, and any Federal, State or Local Government Agency, with a complete copy of any and all medical information for use and disclosure as described in this authorization. Further to release any medical and other information in your possession or control to International Claims Services (ICS) and/or their attorneys, either directly or through a representative agent acting on their behalf, any and all medical information they may request, including but not limited to, medical records, reports, charts, graphs, x-ray notes, films, and laboratory reports. I also hereby authorize the release of all medical information regarding diagnosis, care and treatment for alcohol abuse, drug abuse or mental health. In addition, I authorize the release of any and all billing records and statements in your possession or control. I also authorize ICS, its representatives or their agents to release information that is obtained pursuant to this authorization to providers of healthcare, insurers, reinsurers, or claims administrators, and any government agency as it deems appropriate solely for the purpose of evaluating and administering any claim for benefits. I further understand that information may be released as follows: To other persons or organizations performing business or legal services in connection with any claim; As may be otherwise lawfully required; To any person or legally authorized representative as I have so indicated; As I may further authorize; or as necessary to prevent or detect the perpetration of fraud. This “Authorization For Release of Medical Information” is subject to revocation at any time except to the extent that action has been taken in reliance hereon and, if not earlier revoked in writing, it shall remain valid for two (2) years from date of signature. I agree that a photocopy, e-mailed copy or facsimile (FAX) copy of the authorization shall be accepted and as valid as the original. I know that I may request to receive a copy of this Authorization. Insured Person Name: Signature: By typing my name on this form, I am signing electronically and this electronic signature is the legal equivalent of my manual, handwritten signature. Date: Please send completed claim form and supporting documents (INCLUDING PROOF OF TRAVEL) to: International Claims Services: • Online claims sub...
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I hereby authorize any physician who has information about my medical condition or my past medical history to furnish such information to Well-Spring, A Life Plan Community for the purposes of evaluating my health any physical condition for acceptance into Well-Spring. _
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. TO: (insert name and address of your Doctor or any Medical Practitioner who you are requesting to release your information): Print name of individual authorizing use or disclosure: (Individual): SIN#: Address: Telephone #: PARTY RECEIVING INFORMATION: This information may be disclosed to, and used by, the producers and staff of the program currently entitled “Wipeout Canada” and their authorized agents (the “Series”) c/o 1817141 Ontario Inc., 00 Xxxxxxxx Xx. Suite 400, Toronto, Ontario, M6J 2R9 AUTHORIZATION AND PURPOSE: I authorize the use or disclosure of any and all of my records, including without limitation those pertaining to mental health, steroid use, HIV/AIDS, genetic testing and/or substance abuse. The party to which this authorization is addressed is authorized to release all such records pertaining to services rendered to me or claims or enrollment information pertaining to me for purposes of selecting or eliminating participants in the Series, for quality assurance and peer review, and for any other purpose related to the operation of the Series.
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I authorize the release of all or any part of the contents of my medical records to the following: (1) to persons, corporations or other entities responsible for payment of all or part of my hospital or physician charges including, but not limited to, hospital or medical services companies, insurance companies, workers’ compensation carriers, employers, any and all government agencies, welfare agencies; (2) to persons, corporations or other entities providing health care services and supplies to me in cooperation with Xxxxxxx, its staff and employees during my hospitalization, whose services are deemed necessary and requested by my treating physician; (3) to persons, corporations or other entities providing accounting, billing, credit, payment, or collections services to, for, or in cooperation with Xxxxxxx; and (4) to any health care provider(s) that will provide continuation of my health care immediately following my discharge from Xxxxxxx. I further authorize disclosure of my medical record and any written communications, reports, or other data concerning my treatment while a patient at Xxxxxxx to my insurance carrier.
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION. I authorize the examining health care practitioner to disclose to the Department of Social Services any information provided, any diagnoses made, conditions revealed, functional limitations and any prognoses identified, as a result of the examination given. I understand that this information will be treated as confidential. Client Signature x Date: AUTORIZACIÓN DE REVELACIÓN DE DATOS MÉDICOS Autorizo al médico examinador a revelar al Departamento de Servicios Sociales todo dato relativo a diagnósticos, aflicciones médicas, limitaciones funcionales y todo prognosis detectado como resultado del examen realizado. Entiendo que estos datos son de carácter confidencial. Firma del Cliente x Fecha:
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Related to AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

  • Information Release Authorization Throughout the Term, you authorize DES to obtain information from the DSP that includes, but is not limited to, your account name, account number, billing address, service address, telephone number, standard offer service type, meter readings, and, when charges hereunder are included on your DSP xxxx, your billing and payment information. You authorize DES to release such information to third parties, including affiliates that need to know such information in connection with your Retail Power service. These authorizations will remain in effect as long as this Agreement is in effect.

  • Customer Information and Release Authorization Throughout this Agreement, you authorize Clearview Energy or its agents to obtain and review information from credit-reporting agencies regarding your credit history and information from the Utility relating to you and your account that includes, but is not limited to: account name and number; billing history; payment history; rate classification; historical and future electricity usage; meter readings; and characteristics of electricity service. Clearview Energy will not provide or sell such information to any other party without your consent unless required to do so by law, or it is necessary to enforce the terms of this Agreement. Clearview Energy reserves the right to reject your enrollment, or terminate this Agreement, in the event you rescind these authorizations.

  • RELEASE OF GENERAL INFORMATION TO THE PUBLIC AND MEDIA NASA or Partner may, consistent with Federal law and this Agreement, release general information regarding its own participation in this Agreement as desired. Pursuant to Section 841(d) of the NASA Transition Authorization Act of 2017, Public Law 115-10 (the "NTAA"), NASA is obligated to publicly disclose copies of all agreements conducted pursuant to NASA's 51 U.S.C. §20113(e) authority in a searchable format on the NASA website within 60 days after the agreement is signed by the Parties. The Parties acknowledge that a copy of this Agreement will be disclosed, without redactions, in accordance with the NTAA.

  • Information Release a. Grantee shall keep and maintain public records required by DEO to perform Grantee’s responsibilities hereunder. Grantee shall, upon request from DEO’s custodian of public records, provide DEO with a copy of the requested records or allow the records to be inspected or copied within a reasonable time per the cost structure provided in chapter 119, F.S., and in accordance with all other requirements of chapter 119, F.S., or as otherwise provided by law. Upon expiration or termination of this Agreement, Grantee shall transfer, at no cost, to DEO all public records in possession of Grantee or keep and maintain public records required by DEO to perform the service. If the Grantee keeps and maintains public records upon completion of the Agreement, the Grantee shall meet all applicable requirements for retaining public records. All records stored electronically must be provided to DEO, upon request from the DEO’s custodian of records, in a format that is compatible with the information technology systems of DEO.

  • Confidentiality and Safeguarding of University Records; Press Releases; Public Information Under this Agreement, Contractor may (1) create, (2) receive from or on behalf of University, or (3) have access to, records or record systems (collectively, University Records). Among other things, University Records may contain social security numbers, credit card numbers, or data protected or made confidential or sensitive by Applicable Laws. [Option (Include if University Records are subject to FERPA.): Additional mandatory confidentiality and security compliance requirements with respect to University Records subject to the Family Educational Rights and Privacy Act, 20 United States Code (USC) §1232g (FERPA) are addressed in Section 12.41.] [Option (Include if University is a HIPAA Covered Entity and University Records are subject to HIPAA.): Additional mandatory confidentiality and security compliance requirements with respect to University Records subject to the Health Insurance Portability and Accountability Act and 45 Code of Federal Regulations (CFR) Part 160 and subparts A and E of Part 164 (collectively, HIPAA) are addressed in Section 12.26.] Contractor represents, warrants, and agrees that it will: (1) hold University Records in strict confidence and will not use or disclose University Records except as (a) permitted or required by this Agreement, (b) required by Applicable Laws, or (c) otherwise authorized by University in writing; (2) safeguard University Records according to reasonable administrative, physical and technical standards (such as standards established by the National Institute of Standards and Technology and the Center for Internet Security [Option (Include if Section 12.39 related to Payment Card Industry Data Security Standards is not include in this Agreement.):, as well as the Payment Card Industry Data Security Standards]) that are no less rigorous than the standards by which Contractor protects its own confidential information; (3) continually monitor its operations and take any action necessary to assure that University Records are safeguarded and the confidentiality of University Records is maintained in accordance with all Applicable Laws and the terms of this Agreement; and (4) comply with University Rules regarding access to and use of University’s computer systems, including UTS165 at xxxx://xxx.xxxxxxxx.xxx/board-of-regents/policy-library/policies/uts165-information-resources-use-and-security-policy. At the request of University, Contractor agrees to provide University with a written summary of the procedures Contractor uses to safeguard and maintain the confidentiality of University Records.

  • Required Confidential Information Status Form CONFIDENTIAL INFORMATION SUBMITTED IN RESPONSE TO COMPETITIVE PROCUREMENT REQUESTS OF EDUCATION SERVICE CENTER REGION 8 AND TIPS (ESC8) IS GOVERNED BY TEXAS GOVERNMENT CODE, CHAPTER 552 If you consider any portion of your proposal to be confidential information and not subject to public disclosure pursuant to Chapter 552 Texas Gov’t Code or other law(s), you must attach a copy of all claimed confidential materials within your proposal and put this COMPLETED form as a cover sheet to said materials then scan, name “CONFIDENTIAL” and upload with your proposal submission. (You must include all the confidential information in the submitted proposal. The copy uploaded is to indicate which material in your proposal, if any, you deem confidential in the event the receives a Public Information Request.) ESC8 and TIPS will follow procedures of controlling statute(s) regarding any claim of confidentiality and shall not be liable for any release of information required by law. Upon your claim and your defense to the Office of Texas Attorney General is required to make the final determination whether the information submitted by you and held by ESC8 and TIPS is confidential and exempt from public disclosure. Tobii Dynavox LLC Name of company Xxxx Xxxxxxxx, President, North American Market Printed Name and Title of authorized company officer declaring below the confidential status of material 0000 Xxxxxxx Xx., Suite 400 Pittsburgh PA 15203 800-344-1778 Address City State ZIP Phone ALL VENDORS MUST COMPLETE THE ABOVE SECTION. I DO CLAIM parts of my proposal to be confidential and DO NOT desire to expressly waive a claim of confidentiality of all information contained within our response to the solicitation. The attached contains material from our proposal that I classify and deem confidential under Texas Gov't Code Sec. 552 or other law(s) and I invoke my statutory rights to confidential treatment of the enclosed materials. ATTACHED ARE COPIES OF PAGES OF CLAIMED CONFIDENTIAL MATERIAL FROM OUR PROPOSAL THAT WE DEEM TO BE NOT PUBLIC INFORMATION AND WILL DEFEND THAT CLAIM TO THE TEXAS ATTORNEY GENERAL IF REQUESTED WHEN A PUBLIC INFORMATION REQUEST IS MADE FOR OUR PROPOSAL. Signature Date 2/3/2020 OR I DO NOT CLAIM any of my proposal to be confidential, complete the section below.

  • News/Information Release The Contractor agrees that it will not issue any news releases in connection with either the award of this Contract or any subsequent amendment of or effort under this Contract without first obtaining review and written approval of said news releases from the County through the County’s Project Manager.

  • Release of Confidential Information No Party shall release or disclose Confidential Information to any other person, except to its Affiliates (limited by FERC Standards of Conduct requirements), subcontractors, employees, consultants, or to parties who may be considering providing financing to or equity participation with Developer, or to potential purchasers or assignees of a Party, on a need-to-know basis in connection with this Agreement, unless such person has first been advised of the confidentiality provisions of this Article 22 and has agreed to comply with such provisions. Notwithstanding the foregoing, a Party providing Confidential Information to any person shall remain primarily responsible for any release of Confidential Information in contravention of this Article 22.

  • NEPOTISM DISCLOSURE A. In this section the term “relative” means:

  • Confidentiality of Contractor Information The Contractor acknowledges and agrees that this Contract and any and all Contractor information obtained by the State in connection with this Contract are subject to the State of Vermont Access to Public Records Act, 1 V.S.A. § 315 et seq. The State will not disclose information for which a reasonable claim of exemption can be made pursuant to 1 V.S.A. § 317(c), including, but not limited to, trade secrets, proprietary information or financial information, including any formulae, plan, pattern, process, tool, mechanism, compound, procedure, production data, or compilation of information which is not patented, which is known only to the Contractor, and which gives the Contractor an opportunity to obtain business advantage over competitors who do not know it or use it. The State shall immediately notify Contractor of any request made under the Access to Public Records Act, or any request or demand by any court, governmental agency or other person asserting a demand or request for Contractor information. Contractor may, in its discretion, seek an appropriate protective order, or otherwise defend any right it may have to maintain the confidentiality of such information under applicable State law within three business days of the State’s receipt of any such request. Contractor agrees that it will not make any claim against the State if the State makes available to the public any information in accordance with the Access to Public Records Act or in response to a binding order from a court or governmental body or agency compelling its production. Contractor shall indemnify the State for any costs or expenses incurred by the State, including, but not limited to, attorneys’ fees awarded in accordance with 1 V.S.A. § 320, in connection with any action brought in connection with Contractor’s attempts to prevent or unreasonably delay public disclosure of Contractor’s information if a final decision of a court of competent jurisdiction determines that the State improperly withheld such information and that the improper withholding was based on Contractor’s attempts to prevent public disclosure of Contractor’s information. The State agrees that (a) it will use the Contractor information only as may be necessary in the course of performing duties, receiving services or exercising rights under this Contract; (b) it will provide at a minimum the same care to avoid disclosure or unauthorized use of Contractor information as it provides to protect its own similar confidential and proprietary information; (c) except as required by the Access to Records Act, it will not disclose such information orally or in writing to any third party unless that third party is subject to a written confidentiality agreement that contains restrictions and safeguards at least as restrictive as those contained in this Contract; (d) it will take all reasonable precautions to protect the Contractor’s information; and (e) it will not otherwise appropriate such information to its own use or to the use of any other person or entity. Contractor may affix an appropriate legend to Contractor information that is provided under this Contract to reflect the Contractor’s determination that any such information is a trade secret, proprietary information or financial information at time of delivery or disclosure.

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