Hawaii Authorization to Disclose Protected Health Information Form - Free Download
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Hawaii Authorization to Disclose Protected Health Information Form
Hawaii Authorization to Disclose Protected Health Information Form
ST. FRANCIS HEALTHCARE SYSTEM OF HAWAII
1. By signing this Authorization form, I give permission to:
2. To disclose my health information to:
Name: Telephone:
Address:
3.
4. Type of record(s) to be disclosed:
Discharge summary Pathology reports Complete medical record
Medical history and physical Emergency room records Billing records
Consultation reports X-ray and imaging reports
Other:
Operative reports X-ray films
5. Dates of Treatment:
From:
To:
6. I specifically authorize disclosure of the following restricted health information:
______Initials Records containing information about HIV Infection, AIDS or AIDS Related Complex (ARC)
______Initials Records containing information about diagnosis or treatment of a mental illness
______Initials Records containing information about treatment for alcohol and/or drug abuse
7. I understand that I do not have to sign this Authorization form. If I do not sign this form, my decision will not affect my
treatment, payment for my treatment, my continued enrollment in a health plan, or my continued eligibility for health
plan benefits, except as allowed by law.
8. I understand that some of the persons who receive my health information, based upon this Authorization, may not be
required to follow Federal privacy laws. Therefore, my health information may no longer be protected by law. There is
a chance that my health information may be shared with others without my permission.
9. I have the right to revoke (take back) this Authorization at any time. To revoke this Authorization, I must write to the
Health Information Management department. I understand that the revocation will not apply to actions St. Francis
Healthcare System of Hawaii or its Subsidiary Corporations have already taken based upon this Authorization. I also
understand that the revocation will not apply to my insurance company when the law provides my insurance company
with the right to contest a claim under my policy.
For the purpose of:
10. Unless revoked, this Authorization will expire on the following date or event:
If an expiration date or event is not specified, this Authorization will expire in one year.
_____________________________________________ ___________________________
Signature of Patient or Patient's Personal Representative Date
Print Name of Personal Representative Witness (if patient signs with a "mark")
Durable Power of Attorney for Health Care Decisions Parent of minor
Authority of Personal Representative:
Guardian Surrogate Executor
Other:
Revised 9/21/10
AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION
St. Francis Hospice
St. Francis Home Care Services
Other - Name:
Address:
Patient's Name:
Date of Birth:
Telephone #:
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