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AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR …
Voluntary. Failure to sign the authorization form will result in the non-release of the protected health information. This form will not be used for the authorization to disclose alcohol or drug abuse patient information from medical records or for authorization to disclose information from records of an alcohol or drug abuse treatment program.
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Information Assurance Workforce Improvement …
www.esd.whs.milDoD 8570.01-M Information Assurance Workforce Improvement Program Incorporating Change 4, 11/10/2015 December 19, 2005 Assistant Secretary of …
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Department of Defense - Washington Headquarters …
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DoD Instruction 6055.15, May 4, 2007
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AUTHORIZATION TO DISCLOSE INFORMATION
policies.ncdhhs.govStates, and some individual sources of information, require that the authorization specifically name the source that you authorize to release personal information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if we need you to sign more authorizations.
Authorization for Use or Disclosure of Protected Health ...
my.therapysites.comThe information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected health information. _____ _____ Signature Date If signed by a personal representative:
INFORMATION AND INSTRUCTIONS TO HELP YOU …
www.veteransaidbenefit.orgINFORMATION AND INSTRUCTIONS TO HELP YOU COMPLETE THE AUTHORIZATION TO DISCLOSE PERSONAL INFORMATION TO A THIRD PARTY SPECIFIC INSTRUCTIONS Questions 1 - 5 In this section, give us the veteran's identification information to include name, social security number, VA file number, date
Record Request: Authorization to Use and Disclose ...
ufhealth.orgThis authorization allows UF Health to use and disclose (release) certain PHI, which includes medical records, as I have directed. I understand that: • The PHI may include information about mental health, substance and/or alcohol use, HIV/AIDS, and STDs.
Authorization for the Use and Disclosure of Protected ...
ahca.myflorida.commental health treatment information, this authorization must include a statement of the specific information that you are giving the Agency permission to disclose (for example, “For the purposes of my assessment, treatment plan, attendance, or discharge plan.”)