Patient Authorization for Practice to Release Protected Health Information
Please correct the errors described below.
Dermatology Associates requires all patients to complete this form to indicate patient authorization to use and/or disclose certain protected health information (PHI) to the party or parties listed below in compliance with the Health Insurance Portability and Accountability Act (HIPAA). Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. On occasion, the patient and the Practice may want to use PHI for reasons other than treatment, payment, and health care operations, or for other purposes permitted by law.
I authorize all Dermatology Associates of Morris staff to use or disclose to the following individual(s) until the specified expiration date(s):
The above mentioned Protected Health Information may be subject to re-disclosure by the party receiving the information and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that Dermatology Associates has acted in reliance upon this authorization. My written revocation must be submitted to Tara Strauss, Privacy Officer, at 199 Baldwin Road, Parsippany, New Jersey 07054.
(If patient is under 18 or unable to sign)
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
(Patient, Parent, or Authorized Representative)
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