Authorization Under Hipaa And Cmia For Use And Disclosure Of Protected Health Information Page 2

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(f)
Any partner of any partnership of which I am a member when
asked by the partner to do so for any purpose related to the
partner’s capacity as a partner in the partnership;
(g)
A guardian ad litem, if one is appointed for me, when asked by the
guardian ad litem to do so for any purpose related to the guardian
ad litem’s fiduciary capacity;
(h)
A clergy member upon request specific to me for any purpose; and
(i)
OTHER: [fill in the name(s) of other individuals or indicate “None”.]
2.
I intend for the individuals named in the above paragraph to be dealt
with by all my health care providers, as required by HIPAA and CMIA, in
the exact same way as I would be treated with respect to my rights
regarding the use and disclosure of my identifiable protected health
information or other medical records.
3.
I understand that:
(a)
I may revoke this authorization at any time by written notice to the
covered entity;
(b)
The covered entity may not condition treatment, payment,
enrollment, or eligibility for benefits on whether I sign an
authorization unless the law allows conditions; and
(c)
I have a right to a copy of this authorization.
4.
Although information disclosed by a health care provider pursuant to
this authorization is subject to redisclosure and may no longer be protected
by the privacy rules of HIPAA, California law prohibits the further disclosure
of this information without a new authorization. It is my intention that this
authorization form be construed to be a "new authorization that meets the
requirements of Section 56.11" under California Civil Code Section 56.13 to
permit further authorization by recipients of information initially received
under this authorization.
5.
This authority shall supersede any prior agreement that I may have
made with my health care providers to restrict access to or disclosure of my
individually identifiable health information. This authorization shall expire
two (2) years after my death unless validly revoked prior to that date.
Dated:__________________
Print:____________________________
Page 2 of 2
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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