"Medicaid Non-emergency Medical Travel Authorization for the Use or Disclosure of Protected Health Information" - South Dakota

Medicaid Non-emergency Medical Travel Authorization for the Use or Disclosure of Protected Health Information is a legal document that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota.

Form Details:

  • Released on April 1, 2019;
  • The latest edition currently provided by the South Dakota Department of Social Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.

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MEDICAID NON-EMERGENCY MEDICAL TRAVEL
Authorization for the Use or Disclosure
Of
Protected Health Information
As required by the Health Insurance Portability and Accountability Act of 1996, as amended, the South
Dakota Department of Social Services, Medicaid Non-Emergency Medical Travel (NEMT) Program may
not use or disclose your personally identifiable health information, except as provided in our Notice of
Privacy Practices, without your authorization. Your signature on this form indicates that you are giving
permission for the uses and disclosures of protected health information described herein. You may
revoke this authorization at any time by signing and dating the revocation section on your copy of this
form and return it to the Department.
Section 1: (Patient Information)
I,
Patient/Participant Name: _____________________________________________________________________
Address: ___________________________________________________________________________________
City: ________________________________ State: __________________ Zip Code: _____________________
Date of Birth: _______________________ Phone #: ___________________ Recipient ID #: ________________
hereby authorize the Department of Social Services, Medicaid Non-Emergency Medical Travel Program to
release the information described in Section 2 of this Authorization, to the persons, entities or classes of
persons or entities listed in Section 3 of this Authorization.
Section 2: Information Requested
Specific information requested: All records related to the treatment or payment of healthcare services.
Specific dates of service for the information requested: All dates of services for the term of this
authorization until revoked or terminated as set forth in Section 4.
Purpose of the disclosure: To facilitate services and payment through the Medicaid Non-Emergency
Medical Travel Program.
Section 3: Recipient Information
The specified information is to be released to the following persons, entities or classes of persons or entities:
________________________________________.
Section 4: Disclosures
I understand the information received may include information relating to drug and/or alcohol abuse or
physical/sexual abuse. The South Dakota Department of Social Services, its employees, officers, and medical
providers are hereby released from any legal responsibility or liability for release of the above information to the
extent indicated and authorized herein.
South Dakota Department of Social Services
Authorization for the Use & Disclosure of Health Information (04/2019)
MEDICAID NON-EMERGENCY MEDICAL TRAVEL
Authorization for the Use or Disclosure
Of
Protected Health Information
As required by the Health Insurance Portability and Accountability Act of 1996, as amended, the South
Dakota Department of Social Services, Medicaid Non-Emergency Medical Travel (NEMT) Program may
not use or disclose your personally identifiable health information, except as provided in our Notice of
Privacy Practices, without your authorization. Your signature on this form indicates that you are giving
permission for the uses and disclosures of protected health information described herein. You may
revoke this authorization at any time by signing and dating the revocation section on your copy of this
form and return it to the Department.
Section 1: (Patient Information)
I,
Patient/Participant Name: _____________________________________________________________________
Address: ___________________________________________________________________________________
City: ________________________________ State: __________________ Zip Code: _____________________
Date of Birth: _______________________ Phone #: ___________________ Recipient ID #: ________________
hereby authorize the Department of Social Services, Medicaid Non-Emergency Medical Travel Program to
release the information described in Section 2 of this Authorization, to the persons, entities or classes of
persons or entities listed in Section 3 of this Authorization.
Section 2: Information Requested
Specific information requested: All records related to the treatment or payment of healthcare services.
Specific dates of service for the information requested: All dates of services for the term of this
authorization until revoked or terminated as set forth in Section 4.
Purpose of the disclosure: To facilitate services and payment through the Medicaid Non-Emergency
Medical Travel Program.
Section 3: Recipient Information
The specified information is to be released to the following persons, entities or classes of persons or entities:
________________________________________.
Section 4: Disclosures
I understand the information received may include information relating to drug and/or alcohol abuse or
physical/sexual abuse. The South Dakota Department of Social Services, its employees, officers, and medical
providers are hereby released from any legal responsibility or liability for release of the above information to the
extent indicated and authorized herein.
South Dakota Department of Social Services
Authorization for the Use & Disclosure of Health Information (04/2019)
As stated in the Department’s Notice of Privacy Policies, this Authorization form may be revoked at any time
except to the extent the staff has taken action upon it. If not revoked, this Authorization to release protected health
information will terminate in five (5) years from the date listed in Section 5 of this form or upon the following
specified date: _________________. I understand that this authorization may be revoked at any time, as long as I
do so in writing.
I understand if this information is released to a third party, the information may be released by the person or entity
that receives the information and may no longer be protected by federal or other applicable privacy regulations.
Exception -- drug and/or alcohol treatment information, HIV testing information, and mental health treatment
information may not be re-disclosed without my specific consent.
I understand that I am under no obligation to sign this authorization. If the information requested is necessary to
determine if I am eligible to enroll in benefits available through the South Dakota Department of Social Services
or to determine if another medical program can pay for my health care, I understand that if I choose not to
authorize the disclosure and use of this information, I may not be able to show that I qualify. If the South Dakota
Department of Social Services has been asked to allow or pay for a health care service on my behalf (such as a
test or evaluation) for the purpose of providing the results of those services to someone else, I understand that if
I choose not to authorize the disclosure of that information to the other person, the Department of Social
Services may not allow the service or the payment for the services provided on my behalf.
Section 5: Signatures
___________________________________________________________________________
Signature of participant/patient, parent, guardian, or
Date
authorized representative giving consent
__________________________________________________________________________________________
Print Name
Relationship to Participant/Patient
_________________________________________________________________________________________________________________________________________
If signed by a personal representative, provide a description of the representative’s authority to act for the
participant/patient.
______________________________________________
Telephone number of the participant/patient,
parent, guardian, or authorized representative
for verification of the request for information
REVOCATION OF AUTHORIZATION
I hereby cancel this request to release information effective immediately:
___________________________________________________________________________________________
Signature
Date
South Dakota Department of Social Services
Authorization for the Use & Disclosure of Health Information (04/2019)
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