The following form authorizes an author to use the names of specific people in the author's autobiography. The phrase derivative work as used in this form refers to a work based upon one or more preexisting works, such as a translation, musical arrangement, dramatization, fictionalization, motion picture version, sound recording, art reproduction, abridgment, condensation, or any other form in which a work may be recast, transformed, or adapted.
District of Columbia Release and Authorization to Use Name in Book to be Published
Category:
State:
Multi-State
Control #:
US-01515BG
Format:
Word;
Rich Text
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FAQ
By contrast, an authorization of release of PHI (as opposed to consent) is required by the Privacy Rule for uses and disclosures of protected health information not otherwise allowed by the Rule. The patient must provide the authorization of release of PHI to the covered entity.
The patient may enter the date he/she wants the authorization to expire. The patient may enter an expiration event. The patient may enter a date range of information to be shared. If no expiration date is specified, this authorization is good for 12 months from the date signed in Section IX.
A: ?Consent? is a general term under the Privacy Rule, but ?authorization? has much more specific requirements. The Privacy Rule permits, but does not require, a CE to obtain patient ?consent? for uses and disclosures of PHI for treatment, payment, and healthcare operations.
compliant HIPAA release form must, at the very least, contain the following information: 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.
A HIPAA authorization form, also known as a HIPAA release form, is a document that individual signs for their health provider before the entity may use or disclose their protected health information (PHI).