USE AND DISCLOSURE OF HEALTH INFORMATION. THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND THE PURPOSES FOR WHICH CLEARVIEW MAY USE OR DISCLOSE YOUR HEALTH INFORMATION:
USE AND DISCLOSURE OF HEALTH INFORMATION. PURPOSE To comply with Oklahoma State Law and HIPAA requirements for the use and disclosure of protected health information (PHI) on behalf of OKSHINE participants.
USE AND DISCLOSURE OF HEALTH INFORMATION. This Authorization Form describes different uses and disclosures of health information, including as protected under applicable state and provincial law and also “protected health information” as defined by the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the regulations promulgated thereunder. Unless otherwise revoked by me in writing, this Authorization expires on the expiration date of the rider’s membership with USA BMX (“Expiration Date”). I hereby authorize the following uses and disclosures of my Health Information, as defined below, and as permitted or required by law:
USE AND DISCLOSURE OF HEALTH INFORMATION. As we begin the psychotherapy process, I would like to inform you about the type of work we will be doing together, and any alternative treatments that are available to you. There are many different forms of psychotherapy. I utilize a practice I call "eclectic," meaning it draws from a variety of procedures that have been effective in helping people deal with their emotional and social lives. While benefits can be expected from this treatment, it should be understood that no particular outcome can be guaranteed. We will work together to establish goals for therapy. In the course of our work, the goals may change, and I will assist you in further redefining them. The psychotherapeutic process can sometimes lead to the emergence of upsetting feelings and, on occasion, a patient may feel worse before feeling better. I will ask you to participate in a periodic review of your progress. As your therapist, I place a high value on the confidentiality of the information you share with me. Federal Regulations (HIPAA) allow me to use or disclose Protected Health Information (PHI) from your record in order to provide treatment to you, to obtain payment for the services I provide and for other professional activities (known as “health care operations”). Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Psychologists’ Policies and Practices To Protect the Privacy of Your Health Information, hereafter, “Notice of Privacy Practices”, which you have received, describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. I reserved the right to revise the Notice of Privacy Practices at any time. If I do so, the revised Notice of Privacy Practices will be posted in my office. You may ask for a printed copy of the Notice of Privacy Practices at any time. Please note: There are a few possible exceptions to this confidentiality agreement:
USE AND DISCLOSURE OF HEALTH INFORMATION. This is to inform you that Daughters of Charity Services of San Antonio, hereinafter referred to as DCSSA, may use and disclose your health information that identifies you, and that consists of your past, present or future physical or mental health or condition, the provision of your health care; and the past, present or future payment for the provision of your health care (this health information is referred to herein a “ Protected Health Information”).
USE AND DISCLOSURE OF HEALTH INFORMATION. To the extent you provide health information to CIS for the purpose of making application for insurance products, such information will not be disclosed to nonaffiliated companies for any purpose, except: • To underwrite or administer your insurance policy or related claims; • As required by law; or • As authorized by you.
USE AND DISCLOSURE OF HEALTH INFORMATION
