Fillable Consent to the Disclosure of Personal Health Information (City of Oakland)

Fill Online, Printable, Fillable, Blank Consent to the Disclosure of Personal Health Information (City of Oakland) Form

Use Fill to complete blank online CITY OF OAKLAND (CA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Consent to the Disclosure of Personal Health Information (City of Oakland)

On average this form takes 6 minutes to complete

The Consent to the Disclosure of Personal Health Information (City of Oakland) form is 1 page long and contains:

  • 2 signatures
  • 0 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Oakland

BROWSE CITY OF OAKLAND (CA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
32364 Rev. 2020 06 01 Page 1 of 1 S13; 1259
Consent to the Disclosure of Personal Health Information
I,
Full name of person providing consent (Patient/Client or Substitute Decision-Maker (SDM)
of
Address of person providing consent Telephone number
hereby authorize Homewood Health, which encompasses Homewood Health Centre, Ravensview, The Residence and The
Homewood Clinics
to disclose and obtain personal health information of
Name of patient/client
Date of Birth (YYMMDD)
to/from /
Name of Facility
Name of Individual to receive Information
Information of Individual/Facility to disclose and obtain information:
Address
Telephone Number
Email Address
Fax Number
I understand the purpose for disclosing and obtaining the personal health information to
the person/facility noted above.
Consent and Expiry directives, if any:
Electronic Disclosure:
I authorize faxing/electronic transmission of my unencrypted personal health information for the above recipient. I have been
informed and understand the risk of accidental di
sclosure, and the possibility that the information may be deliberately intercepted
by people other than the intended recipient. ☐ Yes ☐ No
Signature of Witness Signature of patient/client/SDM
Date If other than patient/client, state relationship to patient/client
This consent to disclose personal health information is considered valid for each individual admission/service and
within a reasonable length of time thereafter, or upon expressed withdrawal of consent (or expiry directives) by me.
Homewood’s Statement of Information Practices is available for specific details at HomewoodHealth.com.
Homewood Health discloses and obtains information in compliance with Canada’s Personal Information Protection
and Electronic Documents Act (PIPEDA), or substantially similar provincial privacy law. This form will serve as
expressed, written consent for all of Homewood Health services to release information to the person/facility named.
Reset Form
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Consent to the Disclosure of Personal Health Information (City of Oakland)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 August 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document