Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note: we are required to retain records of your care. Again, if you have questions regarding this notice or our health information privacy policies, please contact the Privacy Officer listed above.
Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You have the right, at any time, to revoke your authorization to disclose your PHI. Simply send a written notice of revocation to the Privacy Officer at the address provided above. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. Again, if you have questions regarding this notice or our health information privacy policies, please contact the Privacy Officer listed above.
Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. This notice is effective on May 1, 2014. Again, if you have any questions regarding this notice or our health information privacy policies, please contact Xxxxx Xxxxxxx, M.D. Signature of Patient (or Parent if minor) Relation Date Authorization to Obtain, Use, and Disclose Protected Health Information Patient Name: last first middle Home Address: city state zip Home Telephone: Date of Birth: I authorize Xxxxx Xxxxxxx, MD and the named party below to exchange written and verbal information including my protected health information, including medical treatment, mental health treatment, educational information for the purpose of providing psychiatric assessment, diagnosis, treatment, or coordinating care unless specified otherwise below. Name/Facility:
Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your identifiable health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your identifiable health information for the reasons described in the authorization. Please note that we are required to retain records of your care.
Right to Provide an Authorization for Other Uses and Disclosures. InterMed willobtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.
Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Authorization will be required for marketing purposes and the sale of protected health information that will result in remuneration type of confidential communication, you must make a written request amendment for as long as the information is kept by or for our to the covered entity along. Any authorization you provide to to Compliance Officer, UltraVoice, Ltd., 00 Xxxxx Xxxxxxx Xxxxxx Xxxx, Xxxxx 00, Xxxxxxx Xxxxxx, XX 00000. (000) 000-0000. Specifying the requested method of contact or the location where you wish to be contacted. Our organization will accommodate reasonable requests. You do not need to give a reason for your request.
Right to Provide an Authorization for Other Uses and Disclosures. My practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to me regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, I will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.
Right to Provide an Authorization for Other Uses and Disclosures. Our organization will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Authorization will be required for marketing purposes and the sale of protected health information that will result in remuneration to the covered entity along. Any authorization you provide to us regarding the use and disclosure of your protected health information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your protected health information for the reasons described in the authorization. Please note that we are required to retain records of your care. 8.
Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. You have the right, at any time, to revoke your authorization to disclose your PHI. Simply send a written notice of revocation to the Privacy Officer at the address provided above. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note, we are required to retain records of your care. Again, if you have questions regarding this notice or our health information privacy policies, please contact the Privacy Officer listed above. APPENDIX D Informed Consent and Agreement for Telehealth Services Consent to Telehealth I understand that checking the “I agree” box below, or providing my signature, handwritten or in electronic format of any kind, on this document constitutes my legal signature. In checking the appropriate box or providing my signature on this document, in any form, I am confirming that I understand and agree to its terms.
Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IIHI for the reasons described in the authorization. Please note, we are required to retain records of your care. Again, if you have any questions regarding this notice or our health information privacy policies, please contact Privacy Officer 404-257-5585. Patient Information Date P ersonal Information Patient Last Name Patient First Name Patient Middle Name Preference for receiving documents: email home address Patient SSN# fax: Patient Date of Birth Preference for receiving phone calls: Patient Home Address home phone number cell phone number Patient Home Phone Number other: Patient Cell Phone Number Patient Email-Address Emergency Contact Information
