Consent to Release Information. Upon request by XXXXX, PROVIDER shall provide XXXXX with authorizations, consents or releases, in connection with any inquiry by XXXXX of any hospital, educational institution, governmental or private agency or association (including without limitation the National Practitioner Data Bank) or any other entity or individual relative to PROVIDER’s professional qualifications, PROVIDER’s mental or physical fitness, or the quality of care rendered by PROVIDER.
Consent to Release Information. We may from time to time give any credit or other information about you to, or receive such information from, (a) any financial institution, credit reporting agency, rating agency or credit bureau, (b) any person, firm or corporation with whom you may have or propose to have financial dealings, and (c) any person, firm or corporation in connection with any dealings you have or propose to have with us. You agree that we may use that information to establish and maintain your relationship with us and to offer any services as permitted by law, including services and products offered by our subsidiaries when it is considered that this may be suitable to you.
Consent to Release Information. All communications with a treating psychologist and all records relating to the provision of psychological services are confidential. Because of this, I will ask you to provide written consent before speaking to, or communicating in writing with, anyone about your care. Examples of times you might want me to communicate with someone on your behalf might be to speak with your physician about whether the use of medication to help manage symptoms of depression is appropriate; to help arrange for you to see a psychiatrist or a neuropsychologist; or to help establish medical leave from work, or financial assistance to cover the cost of therapy, with a disability insurance provider. SIGNING THIS FORM INDICATES THAT YOU HAVE READ AND UNDERSTAND THE CONTENT OF THIS FORM AND THAT YOU AGREE TO THE TERMS OF PAYMENT. Name: Date: Signature: Name: Dr. Xxxxxxxx Xxxxxx Date:
Consent to Release Information. I acknowledge that Pediatric Surgical Subspecialists may release my protected health information as necessary for treatment, payment and health care operations and acknowledge that Seton’s Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis, treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions and laboratory test results, including HIV or the diagnosis of AIDS. I understand that use or disclosure of my protected health information may be necessary before my insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I may be required to pay the entire cost of medical care provided by Pediatric Surgical Subspecialists. I acknowledge and consent to allow Pediatric Surgical Subspecialist to use health information exchange systems to electronically transmit, receive and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information. I may “opt out” and not have my protected health information disclosed through health information exchange systems by providing the signed Seton “opt-out” form to the practice location where I receive treatment.
Consent to Release Information. I acknowledge that Austin Dermatologic Surgery Center may release my protected health information as necessary for treatment, payment and health care operations and acknowledge that Seton’s Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my health history, diagnosis, treatment, prognosis, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions and laboratory test results, including HIV or the diagnosis of AIDS. I understand that use or disclosure of my protected health information may be necessary before my insurer will pay for the cost of my medical treatment and that if I refuse to consent to this disclosure I may be required to pay the entire cost of medical care provided by Austin Dermatologic Surgery Center. I acknowledge and consent to allow Austin Dermatologic Surgery Center to use health information exchange systems to electronically transmit, receive and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information. I may “opt out” and not have my protected health information disclosed through health information exchange systems by providing the signed Seton “opt-out” form to the practice location where I receive treatment.
Consent to Release Information. We will need to talk to your Broker and others involved in the sale. By signing this Agreement, you are authorizing us to communicate and share personal financial information about your Property, marketing strategy, offers received, the Loan, credit history, other liens, and plans for relocation with your Broker and other third parties that could be involved in the sale of your Property, including employees of the United States Treasury and its financial agents, Xxxxxx Xxx and Xxxxxxx Mac.
Consent to Release Information. Prior to sharing Confidential Information with the Vendor, Customer will obtain and retain all necessary consents and permission required by applicable law to disclose information identified in Addendum A to the Vendor. Customer will retain and maintain all such signed consents and permissions for at least one (1) year from the last date such consents and permissions are effective, or longer if required by law.
Consent to Release Information. Patient expressly agrees that Newport-Mesa Audiology may:
Consent to Release Information. All communications with your practitioner and all records relating to the provision of services are confidential. Because of this, I will ask you to provide written consent before speaking to, or communicating in writing with, anyone about your care. Examples of times you might want me to communicate with someone on your behalf might be to speak with a friend, family member, or other support personnel that you would like to be a part of your healing and success process. A copy of the written consent form that I use, titled Consent for Release of Information is located on the final page of this document. SIGNING THIS FORM INDICATES THAT YOU HAVE READ AND UNDERSTAND THE CONTENT OF THIS FORM AND THAT YOU AGREE TO THE TERMS OF PAYMENT. Name: (Client) Signature: Date: Name: (for Xxxxxxx Xxx Wellness) Signature: Date: XXXXXXX XXX WELLNESS Xxxxxxx Xxx Coach/RMT/Creator - Deep Issue Massage Method Mailing Address: Suite 00, 000 – 00 Xxxxxx XX, Xxxxxxx, X0X 0X0 Tel (000) 000-0000 Consent for Release of Information I, , authorize Xxxxxxx Xxx Wellness to: Share the following personal information: With the following individuals: For the following reasons: I am aware of and understand the risks and benefits of consenting, or refusing to consent, to disclose this information. I understand that I may revoke this authorization in writing at any time. The revocation will be effective except to the extent that action has already been taken based on the authorization. Authorization will expire on: Signature of Individual Date
Consent to Release Information. CIBC may from time to time give any credit or other information about the Borrower to, or receive such information from, (i) any financial institution, credit reporting agency, rating agency or credit bureau, (ii) any person, firm or corporation with whom the Borrower may have or proposes to have financial dealings, and (iii) any person, firm or corporation (including any guarantor, if applicable) in connection with any dealings the Borrower has or proposes to have with CIBC, and CIBC may obtain such information from them. The Borrower agrees that CIBC may use that information to establish and maintain the Borrower’s relationship with CIBC and to offer any services as permitted by law, including services and products offered by CIBC’s Subsidiaries when it is considered that this may be suitable to the Borrower.
