ࡱ>  bjbj 8H]""|||||8D ,\, , , , , , ,$.1-,||-,||B,d||,,)h*t`tv)+X,0,*22 *2|* -,-,,2" B: Virginia Department of Health Office of Privacy and Security Authorization for Disclosure of Protected Health Information DISCLOSURE AUTHORIZATION Name:_______________________________________ DOB: ___/__/____ As the person signing this authorization, I understand that: The provision of treatment or payment cannot be conditioned on my signing of this authorization. Any health information re-disclosed by a recipient may no longer be protected by this authorization. The original or copy of the authorization shall be included in my medical record. I have a right to revoke this authorization at any time, except to the extent that action has been taken prior to my request to withhold my medical record. The request must be in writing and will be effective upon delivery to the provider in possession of my medical records. ( I do not authorize disclosure of my health information to anyone, other than for treatment, payment and health care operations I am authorizing ____________________________________ (health department) to disclose my health information to the following organization(s) or person(s) specified below: Beginning DateExpiration DateOrganization(s) or Person(s)Purpose for DisclosureInformation to be DisclosedDate Rescinded (by VDH Staff)Rescinded by (Staff Initials) This information may be disclosed immediately. PERSONAL CARE REPRESENTATIVE ( I do not authorize anyone to act as my personal representative ( I authorize you to discuss my health information with the following individual(s) acting as my personal care representative: Name and Relationship of Personal Care Representative: ALTERNATIVE METHOD OF CONTACT ( I do not wish to be contacted in any way other than my home address and/or phone number.. ( I prefer that you contact me in a way other than my home address and/or phone number. I wish to be contacted in the following manner: Alternative Contact Information:   Print Name Date  Signature Relationship to Patient Date ReviewedStaff Initials This form must be reviewed with the patient at least annually:     This form must be filed in the medical record. A copy of this authorization is available to the patient upon request . 4//14 03 Revsd 2011 =>Kz|}    ӷtcRAc0 hJjh)CJOJQJ^JaJ hJjh&CJOJQJ^JaJ hJjhPCJOJQJ^JaJ hJjhYCJOJQJ^JaJ hJjh 'CJOJQJ^JaJ"hJjh '5>*CJOJQJaJhJjh '5CJOJQJaJhJjhB5CJOJQJaJhJjhB5CJOJQJaJhJjh65OJQJhJjhs5OJQJhJjhaOJQJhJjhyOJQJhJjh6OJQJ>|}  w . 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A copy of this      2 R0    0' \2 060 authorization is available to the patient upon request  2 30    2 50 .  2 80   #2 ;0 4//14 03 Revsd  2 0 2011  2 0    0'@Californian FB------ 72 V30 Virginia Department of Health      2 V0    2 V0    82 h70 Office of Privacy and Security    2 h0   @Californian FB------ 2 z 0 Authorization   2 z!0   P2 z*.0 for Disclosure of Protected Health Information       2 ze0    2 zn0   @Californian FB------  2 00   @"Calibri------ /2 00 DISCLOSURE AUTHORIZATION         2 0  ! X2 30 Name:_______________________________________ DOB:     2 w 0 ___/__/____  2 0  @ Calibri------- @ !Kw- @Californian FB------  2 00    J2 0*0 As the person signing this authorization,  2 %0 I  2 - 0 understand  2 t0 that:   2 0     2 00   @Symbol------@"Arial- - - - - - ---  2 00 - - -   2 70  ---  2 H0 T  22 Q0 he provision of treatment   2 0 or payment   d2 1;0 cannot be conditioned on my signing of this authorization.    2 0    0'---  2 00 - - -   2 70  --- 12 H0 Any health information re    2 0 - 2 0 disclosed  2 !0 by  "2 30 a recipient may   2 0   O2 -0 no longer be protected by this authorization.  2 0    0'---  2 00 - - -   2 70  --- 2 H0 Th  22 Y0 e original or copy of the  2 0 authoriz 2 0 ation  %2 <0 shall be included  2 0   2 0 in  &2 0 my medical record.    2 !0    0'---  2 00 - - -   2 70  --- 2 Hu0 I have a right to revoke this authorization at any time, except to the extent that action has been taken prior to my     0' 2 /H]0 request to withhold my medical record. The request must be in writing and will be effective         +2 /0 upon delivery to the   0' O2 ?H-0 provider in possession of my medical records.    2 ?S0    0'  2 QH0   @Wingdings- - - - - - @Times New Roman- - - - - -  @Times New Roman- - - - - ---- - -   2 c00 q- - -  2 c>0  --- 2 cH0 I  2 cQ0 do  2 c`0  --- 2 cd0 not---  2 cy0   2 c}0 authoriz  2 c0 e  2 c0   2 ca0 disclosure of my health information to anyone, other than for treatment, payment and health care       2 tH 0 operations  2 t0     2 00    2 00 I am   2 S0 authoriz G2 (0 ing ____________________________________ 2 u0   2 0 (h %2 0 ealth department)   2 0   I2 )0 to disclose my health information to the     0' D2 0&0 following organization(s) or person(s)   2 0   "2 0 specified below   2 s0 :  2 v0    0'x0--- 2 0 0xBeginning   2 p0x   2 F0xDate   2 b0x  'x--- 2 z xExpiration    2 x   2 xDate   2 x  'h--- (2 hOrganization(s) or   2  hPerson(s)   2 3h  'h--- 2  hPurpose for    2  hDisclosure   2 h  'd--- &2 dInformation to be     2   dDisclosed   2 Fd  'd--- 2 }dDate   2 k dRescinded   2 d  @Californian FB- - - - - -   2 id(by VDH Staff)  2 d  '--- 2  Rescinded   2 by   2    2   - - -  %2 (Staff Initials)   2   '- @ !/-- @ !/-- @ !G0-- @ !w-- @ !Gx-- @ !-- @ !-- @ !g-- @ !h-- @ !-- @ !w-- @ !c-- @ !Md-- @ !-- @ !G-- @ !-- @ !-- @ !-/-- @ !-w-- @ !--- @ !-g-- @ !--- @ !-c-- @ !--- @ !--x0---  2 0x  'x---  2 ax  'h---  2 h  'h---  2 Qh  'd---  2 d  'd---  2 Md  '---  2   '- @ !/-- @ !G0-- @ !w-- @ !Gx-- @ !-- @ !-- @ !g-- @ !h-- @ !-- @ !w-- @ !c-- @ !Md-- @ !-- @ !G-- @ !-- @ !"/-- @ !"w-- @ !"-- @ !"g-- @ !"-- @ !"c-- @ !"-- @ !"-$x0---  2 0x$  '$x---  2 ax$  '$h---  2 h$  '$h---  2 Qh$  '$d---  2 d$  '$d---  2 Md$  '$---  2 $  '- @ !/-- @ !G0-- @ !w-- @ !Gx-- @ !-- @ !-- @ !g-- @ !h-- @ !-- @ !w-- @ !c-- @ !Md-- @ !-- @ !G-- @ !-- @ !#/-- @ !#w-- @ !#-- @ !#g-- @ !#-- @ !#c-- @ !#-- @ !#-Hx%0---  2 30%xH  'H%x---  2 3ax%H  'Hh%---  2 3%hH  'H%h---  2 3Qh%H  'Hd%---  2 3%dH  'H%d---  2 3Md%H  'H%---  2 3%H  '- @ !$/-- @ !G$0-- @ !$w-- @ !G$x-- @ !$-- @ !$-- @ !$g-- @ !$h-- @ !$-- @ !w$-- @ !$c-- @ !M$d-- @ !$-- @ !G$-- @ !$-- @ !#%/-- @ !H/-- @ !H/-- @ !GH0-- @ !#%w-- @ !Hw-- @ !GHx-- @ !#%-- @ !H-- @ !H-- @ !#%g-- @ !Hg-- @ !Hh-- @ !#%-- @ !H-- @ !wH-- @ !#%c-- @ !Hc-- @ !MHd-- @ !#%-- @ !H-- @ !GH-- @ !#%-- @ !H-- @ !H-@Californian FB------ R2 S0/0 This information may be disclosed immediately.      2 S;0    0'--- 52 d00 PERSONAL CARE REPRESENTATIVE     ---  2 d0   - - - - - - - -   2 t00 q- - -   2 t>0  ---  2 tB0 I  2 tG0   g2 tJ=0 do not authorize anyone to act as my personal representative    2 t0   - - - - - - - -   2 00 q- - -   2 >0  --- 2 F0 I  2 R 0 authorize  2 0   2 0 you to  >2 "0 discuss my health information with     2 0   C2 %0 the following individual(s) acting as   2 0   %2 0 my personal care    2 00 representative  2 0 :  2 0   &0--- >2 0"0&Name and Relationship of Personal       (2 00&Care Representative     2 0&:  2 0&  '&---  2 -&  '- @ !/-- @ !/-- @ !0-- @ !%-- @ !&-- @ !-- @ !-- @ !/-- @ !%-- @ !-&---  2 -&  '- @ !/-- @ !%-- @ !&-- @ !-- @ !/-- @ !/-- @ !/-- @ !0-- @ !%-- @ !%-- @ !&-- @ !-- @ !-- @ !----  2 H0   --- 72 00 ALTERNATIVE METHOD OF CONTACT        ---  2 0   - - -   2 00 q---  2 >0   2 AY0 I do not wish to be contacted in any way other than my home address and/or phone number..       2 g0   - - - - - - - -   2 00 q- - -   2 >0  --- 2 C0 I  /2 L0 prefer that you contact  22 0 me in a way other than my    2 y0 home   2 0 address  2 0 and/ R2 /0 or phone number. I wish to be contacted in the     %2 00 following manner:    2 0    2 0   >&0--- :2 000&>Alternative Contact Information     2 00&>:  2 00&>   2 00&>  '+&---  2 &&+  '- @ !/-- @ !/-- @ !0-- @ !%-- @ !&-- @ !-- @ !-- @ !/-- @ !%-- @ !->,&---  2 8&,>  '- @ !+/-- @ !+%-- @ !+&-- @ !+-- @ !,/-- @ !>/-- @ !>/-- @ !>0-- @ !,%-- @ !>%-- @ !>&-- @ !,-- @ !>-- @ !>----  2 M00     2 _*0   --- 2 o00 Print   2 oP0   2 oT0 Name    2 o|0  ,  2 o0  0  2 o0  0  2 o0  0  2 o80  0  2 oh0  0  2 o0  0 2 o0 Date ---  2 o0   ---  2 *0    2 0 0 Signature  2 k0    2 x0  0  2 0  0  2 0  0  2 0  0  2 80  0  2 h0  0  2 0  0 .2 0 Relationship to Patient     2 X0     2 00    82 00 This form must be reviewed wit       :2 0 h the patient at least annually  2 0 :   2 0   [ 2  [Date Review    2 0[ed  2 ?[  '\---  2 \Staff Initials  2 \  '- @ !-- @ !-- @ !-- @ ![-- @ !\-- @ !-- @ !-- @ !-- @ ![-- @ !-[---  2 [  '\---  2 c\  '- @ !-- @ !-- @ ![-- @ !\-- @ !-- @ !-- @ ![-- @ !-[---  2 [  '\---  2 c\  '- @ !-- @ !-- @ ![-- @ !\-- @ !-- @ !-- @ !-- @ !-- @ !-- @ ![-- @ ![-- @ !\-- @ !-- @ !-- @ !-'--%1`}`--'--%1}--'--%--'--%``--'"Systemwx <:.GwLw H:.--  00//..՜.+,0  hp   Virginia Department of HealthY Virginia Department of Health Title  !"#$&'()*+,./0123456789:;<=>?@ABCDEFHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root Entry Fx`Data %1Table-82WordDocument 8HSummaryInformation(GXuDocumentSummaryInformation8MsoDataStore}8`t`VDDFDQWJA==2}8`t`Item  PropertiesUCompObj r   F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q