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

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Multi-State
Control #:
US-04321BG
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Word; 
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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

A valid authorization for releasing patient information, especially under the New Hampshire Waiver, Release and Authorization to Use a Description of Patient’s Psychological History and Treatment in a Book without Identifying the Name of Patient, should include the patient’s name, the specific information being released, the purpose of the release, and the date of expiration. Additionally, it is important to have the patient's signature to indicate consent. By including these elements, you ensure compliance with legal standards.

The primary requirement of authorization is that it must be voluntary and informed, meaning the patient must understand what they are consenting to. Additionally, the New Hampshire Waiver, Release and Authorization to Use a Description of Patient’s Psychological History and Treatment in a Book without Identifying the Name of Patient must clearly state the scope of the information being shared and the purpose of the release. This requirement protects the patient's rights while allowing for the necessary disclosure of information.

An authorization for the release of information should include the patient's full name, date of birth, and contact information. It must specify the information being released, such as a description of the patient’s psychological history and treatment, and identify the parties involved in the disclosure. Including the New Hampshire Waiver, Release and Authorization to Use a Description of Patient’s Psychological History and Treatment in a Book without Identifying the Name of Patient ensures clarity and compliance with healthcare regulations.

A document signed by the patient that is needed for use an disclosure of protected health information that is not included in any existing consent form agreements.

A Medical Records Release Form is used to request that a health care provider (physician, dentist, hospital, chiropractor, psychiatrist, etc.) release a patient's medical records, either to the patient, a third party (such as an employer or insurance company), or both.

A medical liability waiver form is completed by medical professionals. It is used to get consent to treat a patient while also protecting themselves from liability if the patient is hurt or dies while in their care. This waiver generally also provides the patient of their privacy and legal rights.

Medi-Cal waivers are programs that provide additional services to specific groups of individuals, limit services to specific geographic areas of the state, and provide medical coverage to individuals who may not otherwise be eligible under traditional Medicaid rules.

The medical record information release (HIPAA) form lets a patient allow any person or 3rd party to have access to their health records. The form also allows the added option for healthcare providers to share information with each other.

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.

Patients also have a right to know the identities of individuals or agencies that have accessed their PHI for the past six years.

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