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I have had the opportunity to read and consider the contents of this authorization.  I confirm that the contents are consistent with my direction.

 

With my initials at categories below, I hereby authorize release of:

 

________HIV/AIDS Records       ________Drug Abuse/History Records      _________Mental Health Records

 

________Genetics Records          ________Alcohol Abuse/History Records

 

 

_______________________________________________                  ___________________________________

                                                (Signature)                                                                                                               (Date)

 

Social Security Number__________-_______-____________  OHP Number_______________________________

 

Date of Birth  (Day)______/(Month)___________________/(Year)_________

 

 

Medical or Agency Record Number __________________________________________

 

 

If the individual authorizing disclosure is a minor child or a person for whom legal guardianship, conservatorship, or other equivalent limited legal capacity has been established by law, signature of the individual responsible for the protection of the individual's rights under law must appear below.

 

__________________________________________________                           ____________________________________

Signature of person responsible for rights protection of the individual                 Date

 

 

Printed Name of Individual:_______________________________________________________________________

 

Address of Individual:___________________________________________________________________________

 

Telephone of Individual:________________________            Social Security Number:______-_____-___________

 

Individual's Date of Birth:_______________________

 

 

____________________________________________________________________________

Relationship or Authority of Person Responsible for Rights Protection of the Individual

 

 

 

_____________________

1Protected health information ("PHI") is health information that is created or received by a health care provider, health plan, or health care clearinghouse which relates to: 1) the past, present or future physical or mental health of an individual; 2) the provision of health care to an individual; or 3) the past present or future payment for the provision of health care to the individual.  To be protected, the information must be such that it identifies the individual or provides a reasonable basis to believe that the information can identify the individual.  Authority45 C.F.R. 164.508., effective April 14, 2003.

2These laws apply to health plans, health care providers, and health care clearinghouses.

 

 

OADM Client HIPAA PHI Authorization February 2005

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