Authorization For Release Of Information Form - State Of Alaska 2004
Download a blank fillable Authorization For Release Of Information Form - State Of Alaska 2004 in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Authorization For Release Of Information Form - State Of Alaska 2004 with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Department of Health and Social Services
Division of Senior & Disabilities Services
550 West 8th Ave ● Anchorage, Alaska 99501
(907) 269-3666 ● 1-800-478-9996
AUTHORIZATION FOR RELEASE OF INFORMATION
Name: ______________________________________________________________________________________________________
Record # or Other ID: _______________________________________ Date of Birth: ______________________________________
Other Names under which records might be filed: ___________________________________________________________________
Person/Organization Releasing Information: ________________________________________________________________________
Person/Organization Receiving Information: _______________________________________________________________________
___________________________________________________________________________________________________________
Description of Information To Be Released: (If substance abuse information is to be released from a federally assisted substance
abuse treatment center, then this information must be included in the description)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_____________________________________________________________
The purpose of the release of this information is:
I hereby authorize the use or disclosure of my health care and/or other information as described above. I understand that this
authorization is voluntary. I understand that my records may contain sensitive information. I understand that I may revoke this
authorization at any time by signing the revocation section on the back of this release, or by notifying the individual(s) or organization
releasing this information in writing, but if I do, it won’t have any affect on actions taken on this authorization before my revocation
was received. I understand that the individual(s) or organization releasing this information may condition my treatment, payment,
enrollment in a health plan (if applicable) or eligibility for benefits on whether I provide this authorization. I understand that if the
person(s) or organization authorized to receive this information is not a health plan or health care provider, the released information
may no longer be protected by federal privacy regulations. To the extent that this information is required to remain confidential by
federal or state law, the recipient of this information must continue to keep this information confidential. I understand that I may
request a copy of this signed authorization.
This authorization expires on the following date or event: _____________________________________________________________
___________________________________________________
__________________________________________________
Signature of Client or Personal Representative
Date
(Or Witness if signature is by mark)
___________________________________________________
__________________________________________________
Printed Name of Personal Representative or Witness
Description of Personal Representative’s Authority
NOTE: This authorization was revoked on: __________________ (see reverse or attached revocation statement)
Date
RECIPIENT INFORMATION: If the information released pertains to alcohol or drug abuse, the confidentiality of the information is protected
by federal law (CFR 42 Part 2) prohibiting you from making any further disclosure of this information without the specific written authorization
of the person to whom it pertains or as otherwise permitted by CFR 42 Part 2. A general authorization for the release of medical or other
information if held by another party is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally
investigate or prosecute any alcohol or drug abuse patient.
06-5870 (Rev. 01/12/04)
A PHOTOCOPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL
Page 1 of 2
HIPAA Compliant
ADVERTISEMENT
0 votes
Related Articles
Related forms
Authorization For Release Of Protected Education Information Form - State Of Rhode Island And Providence Plantations Family Court
Legal
Authorization For Release Of Information - United States District Court - Northern District Of Ohio Form
Legal
Form 6433 - Authorization For Release Of Information And Request For Information For Qualified Domestic Relations Order
Legal
Form 08-1468c - Authorization For Release Of Records - Alaska Division Of Occupational Licensing
Legal
Form 06-5906 - Authorization For Release Of Immunization / Tb Records To Comply With Alaska's "no-shots No-school" Law
Legal
Authorization For Release Of Health Information Pursuant To Hipaa For Purpose Of Blood-borne Pathogen Post-exposure Treatment And Follow-up
Medical
Related Categories
Parent category: Legal