Fillable HIPAA FORM 3 ONEIDA COMMUNITY HEALTH CENTER AUTHORIZATION (Oneida Tribe of Indians of Wisconsin)

Fill Online, Printable, Fillable, Blank HIPAA FORM 3 ONEIDA COMMUNITY HEALTH CENTER AUTHORIZATION (Oneida Tribe of Indians of Wisconsin) Form

Use Fill to complete blank online ONEIDA TRIBE OF INDIANS OF WISCONSIN (WI) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

HIPAA FORM 3 ONEIDA COMMUNITY HEALTH CENTER AUTHORIZATION (Oneida Tribe of Indians of Wisconsin)

On average this form takes 5 minutes to complete

The HIPAA FORM 3 ONEIDA COMMUNITY HEALTH CENTER AUTHORIZATION (Oneida Tribe of Indians of Wisconsin) form is 2 pages long and contains:

  • 0 signatures
  • 1 check-box
  • 20 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Oneida Tribe of Indians of Wisconsin

BROWSE ONEIDA TRIBE OF INDIANS OF WISCONSIN (WI) 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 FORM 3
ONEIDA COMMUNITY HEALTH CENTER
AUTHORIZATION
Purpose: This form is used for an individual to authorize use or disclosure of the individual's protected health
information for the purposes stated.
SECTION A: Psychotherapy notes.
Check if this authorization is for psychotherapy notes.
If this authorization is for psychotherapy notes, you must not use it as an authorization for any other type of
protected health information.
SECTION B: Individual authorizing use and/or disclosure.
Name: _______________________________________________________________________________________
Address: ____________________________________________________________________________________
Telephone: ____________________________________________ E-mail: __________________________________
Date of Birth: ____________________________________________ Social Security Number: ______________________
TO THE INDIVIDUAL: Please Read the following and complete the information requested.
No Conditions: This authorization is voluntary. We will not condition your treatment on receiving this authorization.
Effect of Granting this Authorization: The protected health information described below may be disclosed to and/or
received by persons or organizations who are not subject to federal health information privacy laws. These persons
or organizations may further disclose the protected health information, and it may no longer be protected by federal
health information privacy laws.
SECTION C: The use and/or disclosure being authorized.
Purpose of this Authorization:
At request of individual (or the individual's personal representative).
For the following purposes:
Protected Health Information to Be Use and/or Disclosed:
Specifically and meaningfully describe the
protected health information that this authorization will allow to be used and/or disclosed:
Entities Authorized to Use or Disclose:
Name or specifically describe the persons and/or organizations (or
the classes of persons and/or organizations), including us, who will be authorized to make use of and/or to disclose
the protected health information described above:
From: Oneida Community Health Center Phone: (920)869-2711
Address: P.O. Box 365 City, State, Zip: Oneida, WI 54155
HIPAA FORM 3
Entities Authorized to Receive and Use:
Name or specifically identify the persons and/or organizations (or the
classes of persons and/or organizations), including us, whom this authorization will allow to receive and use the
protected health information described above:
To: Phone:
Address: City, State, Zip:
SECTION D: Expiration and revocation.
Expiration: This authorization will expire (complete one):
On
On occurrence of the following event (which must relate to the individual or to the purpose of the use and/or
disclosure being authorized):
Right to Revoke:
You may revoke this authorization at any time by giving written notice of revocation to the
Contact Office listed below. Revocation of this authorization will not affect any action we took in reliance on this
authorization before we received your written notice of revocation.
Contact Office: Oneida Community Health Center – Medical Records
PO Box 365, Oneida, WI 54155
(920) 869-2711
(920) 869-6820 (fax)
INDIVIDUAL'S SIGNATURE.
I,____________________________________________, have had full opportunity to read and consider the
contents of this authorization. I understand that, by signing this forth, I am confirming my authorization for the
use and/or disclosure of my protected health information, as described in this form.
Signature: _______________________________________________ Date:
If this authorization is signed by a personal representative on behalf of the individual, complete the following:
Personal Representative's Name: ___________________________________________
Relationship to Individual: ______________________________________________________________
YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT.
Include this authorization in the individual's records.
Send copy to the Privacy Official.
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 FORM 3 ONEIDA COMMUNITY HEALTH CENTER AUTHORIZATION (Oneida Tribe of Indians of Wisconsin)

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 December 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document