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HIPAA Authorization CA

HIPAA Authorization CA

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Published by: LawPro on Jun 20, 2011
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06/20/2011

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Page 1 of 4
Authorization for Release of Protected Health Information(Valid Authorization Under 45 CFR Chapter 164
@
andCalifornia Civil Code Section 56.05(b))Statement of Intent
: It is my understanding that Congress passed a law entitled theHealth Insurance Portability and Accountability Act (
A
HIPAA
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) that limits use, disclosureor release of my individually identifiable health information (or, sometimes herein,
A
protected medical information
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). This Authorization is being signed because it iscrucial that my health care providers readily use, release or disclose my protectedmedical information to, or as directed by, that person or those persons designated in thisAuthorization in order to allow me the advantage of being able to discuss with, andobtain advice from, others or to facilitate decisions regarding my health care when Iotherwise may not be able to discuss these matters with health care providers withoutregard to whether any health care provider has certified in writing that I am
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incompetent
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for purposes of California Probate Code Sections 4235, 4682 and 4690.1. Appointment of Personal/Authorized Representatives:I, Thomas C. Client, an individual, hereby appoint the following persons, or any of them,as my Personal Representatives for health care disclosure under the Standards forPrivacy of Individually Identifiable Health Care Information (45 CFR Parts 160 and 164)under the Health Insurance Portability and Accountability Act of 1996 (
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HIPAA
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), and asmy Authorized Representatives as that term is defined by California Civil Code
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 56.05(b)(referred to as my
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Personal/Authorized Representative
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):Cynthia M. ClientMary C. ClientPaul B. Client2. Grant of Authority:Therefore, as authorized by 45 CFR Sec(s). 164.502(a)(1)(i) and (iv), 164.502(a)(2)(i),164.524 and 164.528 and CMIA, a covered entity (being a health care provider asdefined by HIPAA) is permitted to use, release and disclose my individually identifiablehealth information pursuant to and in compliance with this valid Authorization.I hereby authorize:
 
 
Page 2 of 4a. All covered persons and entities as defined in HIPAA and CMIA, includingbut not limited to a doctor (including but not limited to a physician,podiatrist, chiropractor, or osteopath), psychiatrist, psychologist, dentist,therapist, nurse, hospitals, clinics, pharmacy, laboratory, ambulanceservice, assisted living facility, residential care facility, bed and boardfacility, nursing home, medical insurance company or any other healthcare provider or affiliate,b. to use, release and disclose the following information:Any and all individually identifiable health care information, reports and/orrecords concerning my medical history, condition, diagnosis, testing,prognosis, treatment, billing information and identity of health careproviders, whether past, present or future and any other informationwhich is in any way related to my health care. Additionally, thisdisclosure shall include the ability to ask questions and discuss thisprotected medical information with the person or entity who haspossession of the protected medical information even if I am fullycompetent to ask questions and discuss this matter at the time. It is myintention to give a full authorization for access to, disclosure and releaseof ANY protected medical information by or to the persons named in thisAuthorization as if each person were me;c. to, or as directed by, my Personal/Authorized Representatives.3. Termination:This Authorization is not affected by, and shall not terminate by reason of, mysubsequent disability or incapacity. This Authorization shall terminate on the earlierof: (1) ______________, 20___ or (2) my written revocation expressly referring tothis Authorization and the date it is actually received by the covered entity. Proof ofreceipt of my written revocation may be by certified mail, registered mail, facsimile, orany other receipt evidencing actual receipt by the covered entity. Such revocationshall be effective upon the actual receipt of the notice by the covered entity except tothe extent that the covered entity has taken action in reliance on it.
 
 
Page 3 of 44. Re-disclosure:By signing this Authorization, I acknowledge that the information used, disclosed orreleased pursuant to this Authorization may be subject to re-disclosure by thepersonal representative or representatives whose name or names are written inparagraph 1 of this Authorization and the information once disclosed will no longerbe protected by the rules created in HIPAA and CMIA. No covered entity shallrequire my Personal/Authorized Representatives to indemnify the covered entity oragree to perform any act in order for the covered entity to comply with thisAuthorization.5. Instructions to my Personal/Authorized Representatives:My Personal/Authorized Representatives shall have the right to bring a legal actionin any applicable forum against any covered entity that refuses to recognize andaccept this Authorization for the purposes that I have expressed. Additionally, myPersonal/Authorized Representatives are authorized to sign any documents that thePersonal/Authorized Representatives deem appropriate to obtain use, disclosure orrelease of the protected medical information.6. Valid Document:A copy or facsimile of this original Authorization shall be accepted as though it wasan original document.7. My Waiver and Release:I hereby release any covered entity that acts in reliance on this Authorization fromany liability that may accrue from the use, release or disclosure of my protectedmedical information in reliance upon this Authorization and for any actions taken bymy Personal/Authorized Representatives.8. Severability:I intend that this authorization conform to United States and California law. In theevent that any provision of this document is invalid, the remaining provisions shallnonetheless remain in full force and effect.

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