Authorization for Release of Protected Health Information Sample Clauses
The "Authorization for Release of Protected Health Information" clause grants permission for a designated party to access and disclose an individual's confidential medical records. Typically, this clause outlines the specific types of health information that may be shared, the parties authorized to receive it, and the duration or circumstances under which the authorization is valid. Its core function is to ensure compliance with privacy laws, such as HIPAA, by obtaining explicit consent before sensitive health data is released, thereby protecting patient privacy while enabling necessary information sharing.
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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, ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇. ▇▇▇▇▇. 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.
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.
Authorization for Release of Protected Health Information. I hereby authorize
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.
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.
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
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?
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.