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Description of information to be disclosed – I authorize the practice to disclose the following protected health information to the entity person, or persons identified above:
**I authorize the entity identified above to disclose or provide protected health information about me to the individual/entity listed below.
**Note: Some fax and email transmission methods are not secure and it is possible for your PHI to be compromised during transmission from out practice. Do not designate fax or email as your preferred method if this is a concern to you. This authorization will expire after 12 months unless otherwise specified by you. You have the right to terminate this authorization at any time by submitting a written request. Termination will be effective upon received written notice. We have no control over the person(s) you have listed to receive your PHI. Therefore, your PHI disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule and will no longer be the responsibility of the practice. A fee may apply.
Medication history is a list of prescriptions that any/all healthcare providers have prescribed for you. This list may consist of information from a variety of sources, including but not limited to, pharmacies health insurers, and hospitals. The information collected will be stored in the practice electronic medical record system and becomes part of your personal medical record.
Medication history is very important in helping providers treat your symptoms and/or illness properly and avoiding potentially dangerous drug interactions.
The medication history information gathered might not include drugs purchased without using your health insurance, over-the-counter medications, supplements, or herbal remedies that you take on your own. It is very important that you and your provider discuss all your medications to ensure that your recorded medication history is 100% accurate.
I give my permission to allow my healthcare provider to obtain my medication history from my pharmacy, my health plans, and my other healthcare providers.
This is the “Opt Out Form” described in the Health Current Notice of Health Information Practices. If you opt out, your healthcare providers will not be able to access your health information through Health Current, Arizona’s health information exchange (HIE)—even in an emergency. If you are filling out this form for another person, the references to “you,” “I” and “my” in this form refer to that other person
If you do not want your health information shared through Health Current, fill in your name and date of birth below. Then, check the box that says, “Opt Out.” Finally, sign the form and give it to your healthcare provider.
Opt Out: I do not want any of my health information shared through Health Current.
If you are signing on behalf of more than one patient (such as your children), you must fill out a separate form for each patient.
Provider Office Only: This section must be completed before sending via secure fax to Health Current.
Si no quiere que su información de la salud sea compartida mediante Health Current, favor de llenar y entregar este formulario a su proveedor de salud médica. Su proveedor de salud médica entregará el formulario a Health Current.
Este es el “Formulario Para Optar por la Exclusión" descrito en la Notificación de Prácticas de Información de la Salud. Si usted se excluye, sus proveedores de salud médica no podrán acceder a su información de salud mediante Health Current, el intercambio en Arizona de información de la salud (HIE)— incluso en una emergencia. Si está llenando este formulario para otra persona, las referencias a "usted", "yo" y "mi" en este formulario se refieren a la otra persona.
Si no quiere que su información de la salud sea compartida mediante Health Current, escriba su nombre, apellido y fecha de nacimiento en lo siguiente. Marque la casilla, “Opto por la Exclusión.” Por último, firme y entregue el formulario a su proveedor de salud médica.
Opto por la Exclusión: No quiero que ninguna de mi información de la salud sea compartida mediante Health Current.
Si está firmando en nombre de más de un paciente (como sus hijos), por favor llene un formulario distinto para cada paciente.
Para uso del Proveedor solamente: This section must be completed before sending via secure fax to Health Current.
You are receiving this notice because your healthcare provider participates in a nonprofit non-governmental health information exchange (HIE) called health current. It will not cost you anything and can help your doctor, healthcare providers, and health plans better coordinate your care by securely sharing your health information. This notice explains how the HIE works and will help you understand you’re right regarding the (HIE) under state and federal law.
In a paper – beast record system, your health information is mailed or faxed to your doctor, but sometimes these records are lost or don’t arrive in time for your appointment. If you allow your health information to be shared through the (HIE), your doctors are able to access it electronically in a secure and timely manner.
The following types of health information may be available:
People involved in your care will have access to your health information. This may include your doctors, nurses, other healthcare providers, health plan in any organization or person who is working on behalf of your healthcare providers and health plan. They may access your information for treatment, care coordination, care or case management, transition of care planning, payment for your treatment, conducting quality assessment and improvement activities, developing clinical guidelines and protocols, conducting patient’s safety activities, and population health services. Medical examiners, public health authorities, organ procurement organizations, and others may also access health information for certain approve Purposes, such as conducting death investigations, public health investigations in Oregon, eye or tissue donation and transplantation, as permitted by applicable law.
Health currently also use your health information as required by law and as necessary to perform services for healthcare providers, health plans and others participating with health current.
The health current board of directors can expand the reasons why healthcare providers and others may access your health information in the future as long as the access is permitted by law. That information is on the health current website at healthcurrent.org/permitted -use.
You also may permit others to access your health information by signing an authorized form they only access to health information described in the authorization form for the purpose is stated on that form.
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