As required by the Health Insurance Portability and Accountability Act (HIPAA) of 2003, Capitol School of Austin must obtain a written consent from you to comply with federal Standards for Privacy of Individually Identifiable Patient Information (the "privacy rule"). I hereby authorize Capitol School of Austin to provide evaluation and therapy services to |
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I further authorize Capitol School of Austin to release and receive protected health information, which may include medical, therapy and billing records for activities related to treatment, payment and health care operations.
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Health Information Release FormMy name below indicates that I hereby authorize the release and disclosure of protected health information to the following people on an as-needed basis as determined by CSA staff: |
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This authorization will EXPIRE upon discharge from patient services or upon my written request to deny future releases. I understand that I can revoke this consent at any time, except to the extent that action has already taken place and, if not expressly revoked earlier, this consent and authorization is valid until revoked by me in writing. Authorized Representative |
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