P0rfners /n Wbment He0/th
Transcript of P0rfners /n Wbment He0/th
P0rfners /n Wbment He0/th
600 Her庇Jge Dr. Ste 2ヱO, Jupit∈均FL 33458
Phone停6り-3与4-ヱ5ヱ5
Fox停6り354-ヱ5ヱ6
AUTHORIZA丁ION TO DiSCLOSE PROTECTED HEALTH INFORMATION
P/eo5e COmp/ete 。// sect’ion5 Q声his H/PAA re/eose舟rm.げony sec亡ion5 Ore庫でb/onk, thisform wi// be
invaiid and it w用not be possible foryour hea冊information to be shared as requested.
Section l -Authorization
give mv permission for
to share the information iisted in Section li ofthis document with the person(s) ororganization(s) i have
SPeCified in Section lV ofthis document.
Section lI - Heaith lnformation
l would liketo givethe above heaithcare organization permission to:
口 DiscIose mvcomplete heaith record including, but not “mitedto, diagnoses, labtest results,
treatment, and b帖ng records fora= conditions.
Or
口 Disciose mvcomplete heaith record exceptforthe fo=owing information:
□ Menta川eaith records
口 CommunicabIediseases inciuding, but not limited to, HiVand AIDS
口 DiscioseAicohoi/drug abuse treatment records
□ Geneticinformation
□ Other:
Form of DiscIosu「e:
□ Eiectroniccopvoraccessvia a web-based portaI
□ Hardcopv
Section i‖- Reason fo「 Disciosu「e
Please deta旧he reason(s) whv information is being shared. 1fyou are initiatingthe request forsha「ing
information and do not wish to listthe reasons forsharing, Write ′at my request′・
7輔s documenr w〃 be伯±αined by th叩rov肋1g Orgoniとo亡ion Jbr seven ycar:S.
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Portnerき/n Wbment Heolth
600 Heritoge Dr. Ste 2ヱO, Jupite'FL 33458
Phone停6リー3与4-ヱ与ヱ与
Fax停6り354一ヱ与ヱ6
AUTHORIZATiON TO DISCLOSE PROTECTED HEAしTH INFORMATION
Section lV-Who Can Receive Mv Heaith而ormation
i give authorization forthe heaIth information detahed in section li of帥s documentto be shared with
thefoiiowing individuai(s) or organization(s):
Name:
Organization
Address:
i understand that the person(s)/organization(s川Sted above mav not be covered bv state/federai ruies
goveming privacv and securitv ofdata and mav be permitted tofurthershare the information that is
PrOVided to them.
Section V- Duration ofAuthorization
This authorization to share mv heaith information is va“d:
□ From to
口 Aii past, PreSent,andfutureperiods
口 The dateofthesignature in sectionVl untilthefoilowingevent
l understandthat l am permitted to revokethis authorization tosha「e mv hea冊data atanvtimeand
Can doso bysubmittinga request in writingto:
Name:
Organization:
Address:
i understand that:
● lnthe eventthat mvinformation has aireadvbeen shared bvthetime mvauthorization is
revoked言t mav be too late to cancel permission to share my heaIth data,
' l understandthat i do not need togiveanvfurtherpermissionforthe information detahed in
Section li to be shared with the person(s) ororganization(s) listed in section iV.
・ l understandthatthefa血retosign/submitthisauthorization o「the cance=ation ofthis
authorization wi‖ not prevent me from receiving anvtreatment or benefits l am entitied to
receive, PrOVided this information is not required to determine if l am eiigibieto receive those
treatments or benefits orto pavforthe services l receive.
7航s documen亡wi〃 be融oined by拓e prov肋ng oI卵面eo的nfor seven ye。ぽ
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P0rtnerき/n Woment Heo/th
600 Heritoge Dr. S亡e 2重りJupiteI声L 33458
Phone停6り-3与4-ヱ与ヱ5
Fax停6リ3与4-ヱ与ヱ6
AUTHORIZATION TO DISCLOSE PROTEC丁ED HEAL丁H INFORMA丁ION
Section VI - Signature
Print Patient Name Date
Signature
ifthisform is beingcompIeted bya person with legai authorityto actan individual’s behalf, SuCh asa
Parent O「 legal guardian ofa minor or heaith care agent, Piease compiete the following information:
Name of person compietingthis form:
Signature of person compietingthis form
Describe below howthis person has legal authoritvto sign this form
7航s documen亡w初be硯α面ed by的e providing o岬clni之。軸onJbr seven yeors.
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