Form PPP-1127A FORFF "Authorization for Disclosure of Protected Health Information" - Arizona

What Is Form PPP-1127A FORFF?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form PPP-1127A FORFF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

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Download Form PPP-1127A FORFF "Authorization for Disclosure of Protected Health Information" - Arizona

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
PPP-1127A FORFF (1-18)
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Health Insurance Portability and Accountability Act of 1996 - 45 C.F.R. § 164.508
Name of person/organization disclosing health information:
Name of individual/client whose specific health information is being disclosed:
Describe the protected health information to be disclosed in sufficient detail to enable both the individual signing this
authorization and DES to clearly identify the health information authorized for disclosure:
Name of person/organization receiving the health information:
Describe the specific purpose of this release. The statement “at the request of the individual” is sufficient when an
individual initiates the authorization:
This authorization’s expiration date, event, or condition:
If no expiration date or condition is specified, this authorization shall expire one year from the date of this authorization.
I understand that I may revoke this authorization at any time by written notice to the person/organization named above
that is disclosing my health information, except to the extent that the disclosure authorized has been acted upon prior to
the receipt of any written revocation.
I understand that I do not have to sign this authorization. I understand that a health care provider or health plan may not
condition treatment, payment, enrollment or eligibility in a health plan or eligibility for health care benefits on my signing
this authorization except as provided under state or federal law.
I understand that once the records and information authorized herein are disclosed, they could be redisclosed by
the recipient(s) and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996.
However, health care service providers generally are bound by contract and law to maintain the confidentiality of the
health information received, especially that relating to HIV infection, AIDS or AIDS-related conditions, substance abuse,
psychological or psychiatric conditions or genetic testing.
I understand that I may have a copy of this signed authorization if I request it.
See reverse for EOE/ADA/LEP/GINA disclosures
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
PPP-1127A FORFF (1-18)
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Health Insurance Portability and Accountability Act of 1996 - 45 C.F.R. § 164.508
Name of person/organization disclosing health information:
Name of individual/client whose specific health information is being disclosed:
Describe the protected health information to be disclosed in sufficient detail to enable both the individual signing this
authorization and DES to clearly identify the health information authorized for disclosure:
Name of person/organization receiving the health information:
Describe the specific purpose of this release. The statement “at the request of the individual” is sufficient when an
individual initiates the authorization:
This authorization’s expiration date, event, or condition:
If no expiration date or condition is specified, this authorization shall expire one year from the date of this authorization.
I understand that I may revoke this authorization at any time by written notice to the person/organization named above
that is disclosing my health information, except to the extent that the disclosure authorized has been acted upon prior to
the receipt of any written revocation.
I understand that I do not have to sign this authorization. I understand that a health care provider or health plan may not
condition treatment, payment, enrollment or eligibility in a health plan or eligibility for health care benefits on my signing
this authorization except as provided under state or federal law.
I understand that once the records and information authorized herein are disclosed, they could be redisclosed by
the recipient(s) and may no longer be protected by the Health Insurance Portability and Accountability Act of 1996.
However, health care service providers generally are bound by contract and law to maintain the confidentiality of the
health information received, especially that relating to HIV infection, AIDS or AIDS-related conditions, substance abuse,
psychological or psychiatric conditions or genetic testing.
I understand that I may have a copy of this signed authorization if I request it.
See reverse for EOE/ADA/LEP/GINA disclosures
PPP-1127A FORFF (1-18) - Page 2
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Health Insurance Portability and Accountability Act of 1996 - 45 C.F.R. § 164.508
Authorizations:
Print or type Full Name of Individual/Client or Personal Representative
Signature of Individual/Client or Personal Representative
Date Signed
Description of personal representative’s authority (If applicable):
This authorization was revoked/withdrawn in writing on:
Signature of staff
NOTE: A Facsimile or Photocopy of this Authorization is Considered To be as Authentic as the Original
[This form is not endorsed or approved by any official organization or entity. It is offered as one basic example of a
HIPAA compliant form. It does not authorize the use or disclosure of substance abuse information or HIV/AIDS related
information. The user of this form assumes all responsibility and liability for its use.]
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
Disponible en español en línea o en la oficina local.
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