DOEA Form 182 "Authorization to Use or Disclose Health Information" - Florida

What Is DOEA Form 182?

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

Form Details:

  • Released on April 1, 2003;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • 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 printable version of DOEA Form 182 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA Form 182 "Authorization to Use or Disclose Health Information" - Florida

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AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
DATE: __________
Florida Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
(850) 414-2000
I authorize DOEA to use and disclose my medical records for the purposes of Treatment, Payment and
Health Care Operations.*
*Treatment includes activities performed by a health care provider, nurse, office staff, and other
types of health care professionals providing care to you, coordinating or managing your care with
third parties, and consultations with and between other health care providers. This authorization
includes treatment provided by any physician who covers my/our practice by telephone as the on-
call physician.
*Payment includes activities involved in determining your eligibility for health plan coverage,
billing and receiving payment for your health benefit claims, and utilization management activities
which may include review of health care services for medical necessity, justification of charges,
pre-certification and pre-authorization.
*Health Care Operations includes the necessary administrative and business functions of our
office.
I further authorize DOEA to use and disclose the following specific health and medical information for the
below listed purpose(s):
Specific medical information consisting of:
For the specific purpose of:
I understand and authorize my designated caregiver or personal representative to receive information
described above.
I understand that I have the right to revoke this Authorization provided that I do so in writing,
except to the extent that DOEA has already used or disclosed the information in reliance on this
Authorization.
_________________________________________________________________
Signature of Client
_________________________________________________________________
Signature of Person Authorized by Law or Client
____________________________________
Date
DOEA Form 182 (04/03)
Page 1 of 2
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
DATE: __________
Florida Department of Elder Affairs
4040 Esplanade Way
Tallahassee, FL 32399-7000
(850) 414-2000
I authorize DOEA to use and disclose my medical records for the purposes of Treatment, Payment and
Health Care Operations.*
*Treatment includes activities performed by a health care provider, nurse, office staff, and other
types of health care professionals providing care to you, coordinating or managing your care with
third parties, and consultations with and between other health care providers. This authorization
includes treatment provided by any physician who covers my/our practice by telephone as the on-
call physician.
*Payment includes activities involved in determining your eligibility for health plan coverage,
billing and receiving payment for your health benefit claims, and utilization management activities
which may include review of health care services for medical necessity, justification of charges,
pre-certification and pre-authorization.
*Health Care Operations includes the necessary administrative and business functions of our
office.
I further authorize DOEA to use and disclose the following specific health and medical information for the
below listed purpose(s):
Specific medical information consisting of:
For the specific purpose of:
I understand and authorize my designated caregiver or personal representative to receive information
described above.
I understand that I have the right to revoke this Authorization provided that I do so in writing,
except to the extent that DOEA has already used or disclosed the information in reliance on this
Authorization.
_________________________________________________________________
Signature of Client
_________________________________________________________________
Signature of Person Authorized by Law or Client
____________________________________
Date
DOEA Form 182 (04/03)
Page 1 of 2
AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION
If DOEA is requesting this Authorization from you for our own use and disclosure or to allow another
health care provider or health plan to disclose information to us:
We cannot condition our provision of services or treatment to you on the receipt of this signed
authorization;
You may inspect a copy of the protected health information to be used or disclosed;
You may refuse to sign this Authorization; and
We must provide you with a copy of the signed authorization.
You have the right to revoke this Authorization at any time, provided that you do so in writing and except
to the extent that we have already used or disclosed the information in reliance on this Authorization.
Unless revoked earlier or otherwise indicated, this Authorization will expire 180 days from the date of
signing or shall remain in effect for the period reasonably needed to complete the request.
You may review DOEA's “Notice Of Privacy Practices” for additional information about the uses and
disclosures of information described in this Authorization prior to signing this Authorization. Please verify
that you have received a copy of our Notice by placing your initials here: _____.
Because we have reserved the right to change our privacy practices in accordance with the law, the
terms contained in the Notice may change also. A summary of the Notice will be posted in our office
indicating the effective date of the Notice in the upper right hand corner. We will offer you a copy of the
Notice on your first visit to us after the effective date of the then current Notice. We will also provide you
with a copy of the Notice upon your request.
As more fully explained in the Notice, you have the right to request restrictions on how we use and
disclose your protected health information for treatment, payment, and health care operations purposes.
We are not required to agree to your request. If we do agree, we are required to comply with your request
unless the information is needed to provide you emergency treatment. Other physicians who provide call
coverage for our office are required to use and disclose your protected health information consistent with
the Notice.
DOEA Form 182 (04/03)
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