USE AND DISCLOSURE OF HEALTH INFORMATION. 1 Signing this document authorizes your Provider (named below) to use and/or disclosure certain information about you, including certain demographic information, contact information, OraQuick HCV Rapid Antibody Test results and insurance information (collectively, “Health Information”). Please provide all information requested or this form cannot be used for its intended purpose. PATIENT NAME: PROVIDER NAME: (“Provider”) PROVIDER’S ADDRESS:
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: To Provide Treatment. Clearview may use or disclose your health information to treat you and coordinate your care within Clearview. For example, your attending physician or other health care professionals involved in your care may use information about your symptoms in order to prescribe appropriate medications. Clearview may also disclose your health care information to individuals outside of Clearview involved in your care, including family members, pharmacists, suppliers of medical equipment, or other health care professionals. To Obtain Payment. Clearview may use or disclose your health information to xxxx or collect payment for services or items you receive from Clearview. For example, Clearview may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Clearview. Clearview may also need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care and the services that will be provided to you. To Conduct Health Care Operations. Clearview may use or disclose your health information for our own operations in order to facilitate the functioning of Clearview and as necessary to provide quality care to all Clearview residents. For example, Clearview may use your health information to evaluate how we may more effectively serve all Clearview residents, disclose your health information to Clearview staff, and contracted personnel for training purposes, or use your health information to contact you or your family as part of general community information mailings. Clearview may also disclose your health information to a health oversight agency performing activities authorized by law, such as investigations or audits. These agencies include governmental agencies that oversee the health care system, government benefit programs, and organizations subject to government regulation and civil rights laws. In addition, Clearview may disclose your health information to another health care provider subject to Federal privacy protection laws, as long as the provider has or has had a relationship with you and the information is for that provider’s health care operations.
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. 1. 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. 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. 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
