Authorization for Release of Protected Health Information Sample Clauses

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.
Sample 1Sample 2Sample 3See All (14)
AutoNDA by SimpleDocs
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.
Sample 1Sample 2Sample 3See All (6)
Authorization for Release of Protected Health Information. I hereby authorize
Sample 1Sample 2Sample 3See All (5)
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.
Sample 1Sample 2
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.
Sample 1
Authorization for Release of Protected Health Information. I authorize the following entities to disclose my health information to Sustainable Montana, its affiliated companies, and their officers, directors, volunteers, agents, employees and their authorized representatives (for purposes of this paragraph, collectively "Sustainable Montana"): 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 Sustainable Montana 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, One Beaver Valley Rd, Wilmington, DE. 19803. Such revocation shall not have any effect on actions that the Company and/or Sustainable Montana took in reliance on the Authorization prior to each receiving notice of the revocation.
Sample 1
Authorization for Release of Protected Health Information. I hereby authorize DeKalb Medical Wellness Center to release the following health information: ( ) My complete Wellness Center file
Sample 1
AutoNDA by SimpleDocs
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?
Sample 1

Related to Authorization for Release of Protected Health Information

  • Amendment of Protected Health Information 8.1 To the extent Covered Entity determines that any Protected Health Information is maintained by Business Associate or its agents or Subcontractors in a Designated Record Set, Business Associate shall, within ten (10) business days after receipt of a written request from Covered Entity, make any amendments to such Protected Health Information that are requested by Covered Entity, in order for Covered Entity to meet the requirements of 45 C.F.R. § 164.526. 8.2 If any Individual requests an amendment to Protected Health Information directly from Business Associate or its agents or Subcontractors, Business Associate shall notify Covered Entity in writing within five (5) days of the receipt of the request. Whether an amendment shall be granted or denied shall be determined by Covered Entity.

  • ACCESS TO PROTECTED HEALTH INFORMATION 7.1 To the extent Covered Entity determines that Protected Health Information is maintained by Business Associate or its agents or Subcontractors in a Designated Record Set, Business Associate shall, within two (2) business days after receipt of a request from Covered Entity, make the Protected Health Information specified by Covered Entity available to the Individual(s) identified by Covered Entity as being entitled to access and shall provide such Individuals(s) or other person(s) designated by Covered Entity with a copy the specified Protected Health Information, in order for Covered Entity to meet the requirements of 45 C.F.R. § 164.524. 7.2 If any Individual requests access to Protected Health Information directly from Business Associate or its agents or Subcontractors, Business Associate shall notify Covered Entity in writing within two (2) days of the receipt of the request. Whether access shall be provided or denied shall be determined by Covered Entity. 7.3 To the extent that Business Associate maintains Protected Health Information that is subject to access as set forth above in one or more Designated Record Sets electronically and if the Individual requests an electronic copy of such information, Business Associate shall provide the Individual with access to the Protected Health Information in the electronic form and format requested by the Individual, if it is readily producible in such form and format; or, if not, in a readable electronic form and format as agreed to by Covered Entity and the Individual.

  • Electronic Protected Health Information “Electronic Protected Health Information” means individually identifiable health information that is transmitted by or maintained in electronic media.

  • 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.

  • 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.

  • Data Protection and Privacy: Protected Health Information Party shall maintain the privacy and security of all individually identifiable health information acquired by or provided to it as a part of the performance of this Agreement. Party shall follow federal and state law relating to privacy and security of individually identifiable health information as applicable, including the Health Insurance Portability and Accountability Act (HIPAA) and its federal regulations.

  • 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. 8.1 If deemed necessary by Specialty Emergency Services, for both the correct treatment of the member and to comply with the terms and conditions, the Member allows Specialty Emergency Services to screen for narcotics and any/all forms of mind-altering substances by blood test undertaken by a licensed doctor in a licensed medical facility.

  • Labor Law Information You acknowledge that if you continue to hold shares of Common Stock acquired under the Plan after an involuntary termination of your employment, you may not be eligible to receive unemployment benefits in Russia. Anti-Corruption Information. Anti-corruption laws prohibit certain public servants, their spouses and their dependent children from owning any foreign source financial instruments (e.g., shares of foreign companies such as the Company). Accordingly, you should inform the Company if you are covered by these laws because you should not hold shares of Common Stock acquired under the Plan.

  • Confidentiality of Protected Data (a) Vendor acknowledges that the Protected Data it receives pursuant to the Master Agreement originates from the District and that this Protected Data belongs to and is owned by the District. (b) Vendor will maintain the confidentiality of the Protected Data it receives in accordance with federal and state law (including but not limited to Section 2-d) and the District’s policy on data security and privacy. The District will provide Vendor with a copy of its policy on data security and privacy upon request.

  • Supplemental Vendor Information Only) No response Optional. If Vendor desires that their logo be displayed on their public TIPS profile for TIPS and TIPS Member viewing, Vendor may upload that logo at this location. These supplemental documents shall not be considered part of the TIPS Contract. Rather, they are Vendor Supplemental Information for marketing and informational purposes only. Some participating public entities are required to seek Disadvantaged/Minority/Women Business & Federal HUBZone ("D/M/WBE/Federal HUBZone") vendors. Does Vendor certify that their entity is a D/M/WBE/Federal HUBZone vendor? If you respond "Yes," you must upload current certification proof in the appropriate "Response Attachments" location. NO Some participating public entities are required to seek Historically Underutilized Business (HUB) vendors as defined by the Texas Comptroller of Public Accounts Statewide HUB Program. Does Vendor certify that their entity is a HUB vendor? If you respond "Yes," you must upload current certification proof in the appropriate "Response Attachments" location. No Can the Vendor provide its proposed goods and services to all 50 US States? No

Draft better contracts in just 5 minutes Get the weekly Law Insider newsletter packed with expert videos, webinars, ebooks, and more!