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The document is a 'Sentara Authorization to Disclose Protected Health Information' form, which allows a patient to authorize the use or disclosure of their health information to specified individuals or organizations. It outlines the types of information that can be disclosed, including medical records and test results, and informs the patient of their rights regarding revocation of the authorization and confidentiality concerns. The form requires patient details, signatures, and includes provisions for expiration and voluntary participation.

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What is disclosure authorization?

This is a form used in the nonstandard auto market, for people who do not qualify for automobile insurance from the usual sources because of their bad driving record. Such drivers are required to sign a disclosure authorization form before coverage can be put in force.

What is an authorization to disclose?

A covered entity may disclose PHI without the individuals permission for treatment, payment, and health care operations purposes. For other uses and disclosures, the Privacy Rule generally requires the individuals written permission, which is an authorization that must meet specific content requirements.

What does authorization to disclose mean?

The authorization provided by use of the form means that the organization, entity or person authorized can disclose, commu- nicate, or send the named individuals protected health information to the organization, entity or person identified on the form, including through the use of any electronic means.

What is a VA Form 21 4142 authorization to disclose information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

What is an authorized disclosure?

Disclosure is authorized if the respondent consented to making confidential information known to a third party. An example of authorized disclosure is providing record-level information to a Designated Agent for statistical purposes.

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