Patient Phi
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Applicant Authorization for Use and Disclosure of Personal ...
www.merckhelps.comPatient’s Original Signature _____ Date I understand that in order for the Merck Patient Assistance Program, Inc. (Merck PAP) to provide me with assistance, it will need to obtain, review, use, and disclose my personal health information (PHI), including information relating to my medical condition and information on my application
Consent to Disclose Health Information Form
albertahealthservices.capurpose of responding to your request and will be filed on the patient/client record. If you have questions about the collection and use of any information on this form, contact the Disclosure Help Line at 1.855.312.2265. Office Use Only - This form is not to be used to document a disclosure or release of information.
PATIENT RIGHTS, CONFIDENTIALITY, AND HIPAA PRIVACY
www.gbmc.orgprotected health information (PHI) PHI is medical information that can be traced to, or identified with, a particular patient. PHI is information created or received by a health care organization that relates to the past, present, or future health or condition of an individual.