Danville Fire Department
authorization to use and disclose specific phi
Danville Fire Department and Center Township / Danville
Ambulance Service
Authorization to Use and Disclose
Specific Protected Health Information
By signing this Authorization, I hereby direct the use or disclosure by Danville Fire Department and Center Township / Danville Ambulance Service of certain medical information pertaining to my health, my health care, or me.
This Authorization concerns the following medical information about me:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
This information may be used or disclosed by Danville Fire Department and Center Township / Danville Ambulance Service and may be disclosed to: ________________________________________________________________________________________________________________________________________________
[LIST NAME OR SPECIFIC IDENTIFICATION OF THE PERSON (S) OR CLASS OF PERSONS TO WHOM YOU MAY MAKE THE REQUESTED USE/DISCLOSURE]
I understand that I have the right to revoke this Authorization at any time except to the extent that Danville Fire Department and Center Township / Danville Ambulance Service has already acted in reliance on the Authorization. To revoke this Authorization, I understand that I must do so by written request to the Center Township Ambulance Service Center, Township Trustee Judy White, 115 South Washington Street Danville, Indiana 46122 Office Phone (317) 745-2813.
I understand that information used or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and no longer subject to privacy protections provided by law.
I understand that my written authorization is not required for Danville Fire Department and Center Township / Danville Ambulance Service to use my protected health information for treatment, payment and health care operations.
I understand that I have the right to inspect and copy the information that is to be used or disclosed as part of this Authorization. The Authorization is being requested by Danville Fire Department and Center Township / Danville Ambulance Service for the following purpose (s):
________________________________________________________________________________________________________________________________________________________________________________________________________________________
The use or disclosure of the requested information will ___/will not ___ result in direct or indirect remuneration to Danville Fire Department and Center Township / Danville Ambulance Service from a third party.
I acknowledge that I have read the provisions in the Authorization and that I have the right to refuse to sign this Authorization. I understand and agree to its terms.
_________________________________ [Name] __________________ [Date]
_________________________________ [Description of the authority of personal representative, if applicable]
This authorization expires on: __________________________ (date or event).
[NOTE: It is rare that an authorization form will need to be completed, since authorization is not required to use PHI for treatment, payment or health care operations. A copy of the Authorization must be provided to the individual. Also, you may have to comply with additional requirements, depending on the use of the PHI, such as when you request the authorization for your own use, or when you request the authorization for another covered entity or if the use or disclosure is for research purposes.]