Authorization Under Hipaa And Cmia For Use And Disclosure Of Protected Health Information

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AUTHORIZATION UNDER HIPAA AND CMIA FOR USE AND
DISCLOSURE OF PROTECTED HEALTH INFORMATION
1.
I, _______________________________, hereby authorize, pursuant
to the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
42 USC §1320d and 45 CFR parts 160, 164, and the California
Confidentiality of Medical Information Act (CMIA), Civil Code §§ 56 – 56.37,
any covered entity, including, but not limited to, any physician, health care
professional, dentist, health plan, hospital, nursing home, clinic, laboratory,
pharmacy, any other covered health care provider, any insurance
company, the Medical Information Bureau, Inc., or other healthcare
clearinghouse that has provided treatment or services to me or that has
paid for or is seeking to be paid for services, to give, disclose and release,
without restriction, all of my individually identifiable health information and
medical records governed by HIPAA and CMIA regarding any past, present
or future medical or mental health condition, including, but not limited to,
any and all information relating to the diagnosis and treatment of sexually
transmitted diseases, mental illness (including information contained in
mental health records protected by the Lanterman-Petris-Short Act),
HIV/AIDS, and drug or alcohol abuse, to and upon request by one or more
of the following individuals:
(a)
An agent designated under an advance health care directive even
if I have not been determined to lack capacity;
(b)
An individual designated under a durable power of attorney signed
by me as an individual responsible for determining my capacity
when asked by the individual to do so for any purpose related to
the individual’s role under the durable power of attorney;
(c)
An agent designated under a durable power of attorney signed by
me when asked by the agent to do so for any purpose related to
the agent’s fiduciary capacity;
(d)
An individual designated under a trust for which I am a settlor,
trustee and/or beneficiary as an individual responsible for
determining my capacity when asked by the individual to do so for
any purpose related to the individual’s role under the trust;
(e)
The trustee, or a designated successor trustee, of any trust of
which I am a settlor, trustee and/or beneficiary when asked by the
trustee to do so for any purpose related to the trustee’s fiduciary
capacity;
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A product of:
M
ETA
law, inc.
B e c a u s e e v e r y l i f e n e e d s a g o o d p l a n .

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