Fillable HIPAA Compliant Authorization for Release of Patient Information (Golder Ranch Fire District)

Fill Online, Printable, Fillable, Blank HIPAA Compliant Authorization for Release of Patient Information (Golder Ranch Fire District) Form

Use Fill to complete blank online GOLDER RANCH FIRE DISTRICT (AZ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

HIPAA Compliant Authorization for Release of Patient Information (Golder Ranch Fire District)

On average this form takes 8 minutes to complete

The HIPAA Compliant Authorization for Release of Patient Information (Golder Ranch Fire District) form is 2 pages long and contains:

  • 1 signature
  • 5 check-boxes
  • 26 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Golder Ranch Fire District

BROWSE GOLDER RANCH FIRE DISTRICT (AZ) 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
 
HIPAA Compliant Authorization for Release of Patient Information
Pursuant to 45 CFR 164.508
Section I – Patient Information
Name:
Member ID:
Street Address:
Birth Date:
City:
State:
Zip:
Telephone:
Email:
I, or my authorized representative, hereby authorize Golder Ranch Fire District and their respective
employees to dis
close my Personal Health Information (PHI) and Insurance Record to
the designee identified below.
SECTION II –Authorized Designee (to whom
the information will be sent)
Name:
Relationship:
Street Address:
Telephone:
City:
State:
Zip:
In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand
that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG
ABUSE, SEXUALLY TRANSMITTED DISEASES, MENTAL HEALTH TREATMENT, except
psychotherapy notes, and CONFIDENTIAL ACQUIRED IMMUNODEFICIENCY SYNDROME
(AIDS), OR HUMAN IMMUNODEFICIENCY VIRUS (HIV) RELATED INFORMATION only if I
place my initials on the appropriate line in Section III. In the event the health information
described below includes any of these types of information, and I initial the line on the box in
Section III, I specifically authorize release of such information to the person indicated in
Section II.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health
treatment information, the recipient is prohibited from redisclosing such information without my
authorization unless permitted to do so under federal or state law. I understand that I have the
right to request a list of people who may receive or use my HIV-related information without
authorization.
3. I have the right to revoke this authoriz
ation at any time by writing to Freedom Health. I
understand that I may revoke this authorization, except to the extent that
action has
already been taken bas
ed on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment
in Freedom Health, or eligibility benefits will not be conditioned upon my authorization of
disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient,
and the redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY PERSONAL
HEALTH INFORMATION AND INSURANCE RECORD WITH ANYONE OTHER THAN
THE PERSON AUTHORIZED IN SECTION II.
Section III – Specific Informatio
n to be Released:
☐ Please release my Medical Record from (insert date) ____________ to (ins
ert date) ____________.
☐ Please release my entire Medical Record, including patient history of treatment and/or transportation
and/or refusal of treatmenat and/or transportation including diagonstic records, medications lists, prior
medical history, electrocardiogram tracings and impressions, including any acceptance or refusal of care
and/or transportation for the abovementioned date(s).
Please release all billing records including all statements, insurance claim forms, itemized bills, records of
billing to third party payers and payment or denial of benefits for the abovementioned date(s).
Reason for release of information:
☐ At the request
of the individual
☐ Other: __________________________________________________________________________
If an authorized representative is making this request, please provide your information below and attach
certifying documentation of your status as the authorized representative, such as a Power of Attorney
or Guardianship papers.
AUTHORIZED REPRESENTATIVE
Name:
Relationship:
Street Address:
Telephone:
City:
State:
Zip:
By signing this form, I am confirming that it accurately reflects my wishes. In addition, I have kept a
copy of this form for my records.
_______________________________________ ______________________
Signature of Member or
Authorized Representative Date
State of Arizona
County of __________________________
The foregoing instrument was acknowledged before me this ____day of _______, 20___, at ______________,
Arizona, by ____________________________ to be his/her free act and deed.
___________________________________
Signature of Notary Public
Name of Notary Public (Print): _______________
Notary Public, State of Arizona SEAL
My commission expires: _____________
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

HIPAA Compliant Authorization for Release of Patient Information (Golder Ranch Fire District)

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 20 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document