CpapforMedicare.com, A Division of NOR CAL DIAGNOSTICS
Phone: (866)742-1238
Fax: (916)681-0411
YOUR HEALTH INFORMATION
AUTHORIZATION FOR THE USE AND DISCLOSURE OF
INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION AND ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.
1. Specific description of information that may be used/disclosed:
medical information pertaining to past medical examinations, diagnoses, treatments and/or procedures and treatment of sleep apnea; mainly, a copy of the sleep studies report.____________________________________________________________.
2. The information will be used/disclosed for the following purpose(s): Tests performed by or to provide medical equipment from Nor Cal Diagnostics/CpapforMedicare.com and treatment pertaining to tests or for providing medical equipment.
3. Persons/organizations authorized to use or disclose the information: Nor Cal Diagnostics/CpapforMedicare.com 7600 Hospital Drive Suite E, Sacramento, CA 95823
4. Persons/organizations authorized to receive the information:
Patient’s Primary Care Physician(s) _________________________________________________;
Specialty Physicians:________________________________________________________;
Durable Medical Equipment Companies: NorCal Diagnostics/ CpapforMedicare.com __________.
5. If the purpose of this authorization is to disclose health information to another party based on health care that is provided solely to obtain such information, and I refuse to sign this authorization, the facility reserves the right to deny that health care.
6. I understand that I may inspect or copy the information used or disclosed.
7. I understand that I may revoke this authorization at any time by notifying the facility in writing, except to the extent that action has been taken in reliance on this authorization.
8. I acknowledge that I have received a copy of a Notice of Privacy Practices from the facility.
9. This authorization expires on one year from date listed below or ___________________.
______________________________________ ________________________________
Signature of patient or patient’s representative Date
______________________________________ ________________________________
Printed name of patient or patient’s representative Relationship to patient or representative’s
authority to act for the patient, if applicable
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