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4049195518

Privacy Authorization form


 We keep families in touch

HIPPA

HIPPA-Privacy Authorization Form

Authorization for use Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, C.F. R Parts 160 and 164)


1. Authorization

I authorize   ______________________ ( NTouch) to use and disclose the protected health information described below to NTouch.


2. Effective Period

This authorization for release of information covers the period of healthcare from:

a. {  } _________________ to ________________.

OR

b. {  } all past, present and future periods.


3. This information (Wellness Sheet) may be used by the person I authorize to receive this information for medical treatment or consultation, billing, or claims payment, or other purposes as I may direct.


4. This authorization shall be enforced and effective until ______________ (date) at which time this authorization expires.


5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that  any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.


6. I understand that my treatment, enrollment, payment or eligibility for benefits will not be conditioned on whether I sign this authorization.


7. I understand that information used or disclosed pursuant  to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

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Signature of NTouch member or personal representative



X -----------------------------------------------------------------------------------------------------------------------------

Printed name of member or personal representative and his or her relationship to the member


Date ______________________________





Consent to Call

NTouch is a call center for the elderly, this is a service that may be of interest to you. By submitting this form, you give us your consent  to receive prerecorded messages sent using automated technology to the phone number(s) below, including wireless number if provided. Please note that you are not required to  provide this consent to make a purchase from us.

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Phone # ____________________

           Phone # ____________________ (cell)

                                                               Phone#  ________________________ (personal representative)


Signature of NTouch member or personal representative    X ___________________________________________

 

Printed name of NTouch member or personal representative and his or her relationship to NTouch member X __________________________________

     Date: _________________________