California Waiver, Release and Authorization to Use a Description of Patientýs Psychological History and Treatment in a Book without Identifying the Name of Patient

State:
Multi-State
Control #:
US-04321BG
Format:
Word; 
Rich Text
Instant download

Description

A release gives up a right, such as releasing one from his/her liability for harm or damage that may occur from performing under a contract, or participating in an activity. A release acts as some assurance to the person requesting the release that he/she will not be subjected to litigation resulting from the person giving the release. The term waiver is sometimes used to refer a document that is signed before any damages actually occur. A release is sometimes used to refer a document that is executed after an injury has occurred.


This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.

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FAQ

These elements include: A description of the specific information to be used or disclosed. The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.

An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

More generally, HIPAA allows the release of information without the patient's authorization when, in the medical care providers' best judgment, it is in the patient's interest. Despite this language, medical care providers are very reluctant to release information unless it is clearly allowed by HIPAA.

There are a few scenarios where you can disclose PHI without patient consent: coroner's investigations, court litigation, reporting communicable diseases to a public health department, and reporting gunshot and knife wounds.

A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed. An expiration date or expiration event when consent to use/disclose the information is withdrawn.

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.

Release of information (ROI) is the process of providing access to protected health information (PHI) to an individual or entity authorized to receive or review it.

The patient's legal name, date of birth, gender, Social Security number, address, telephone number, guarantor, subscriber, or next-of-kin are key identifying elements that assist in establishing the proper individual.

The Health and Social (Safety and Quality) Act 2015, which came into effect on 1st October 2015 sets a duty for information to be shared where it facilitates care for an individual and it is legal to do so.

We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

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California Waiver, Release and Authorization to Use a Description of Patientýs Psychological History and Treatment in a Book without Identifying the Name of Patient