Form SFN61353 "Authorization to Disclose Protected Health Information - Crime Victims Compensation" - North Dakota

What Is Form SFN61353?

This is a legal form that was released by the North Dakota Department of Corrections & Rehabilitation - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2019;
  • The latest edition provided by the North Dakota Department of Corrections & Rehabilitation;
  • 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 Form SFN61353 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Corrections & Rehabilitation.

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Download Form SFN61353 "Authorization to Disclose Protected Health Information - Crime Victims Compensation" - North Dakota

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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION – CRIME VICTIMS COMPENSATION
NORTH DAKOTA DEPARTMENT OF CORRECTIONS AND REHABILITATION
SFN 61353 (03-2019)
PRIVACY STATEMENT: Disclosure of the social security number is voluntary and is requested for the purpose of accurate identification. Failure to disclose a
social security number will not affect the disclosure of other information. The DOCR may, however, require that you authorize disclosure of your health
information if needed to make a determination about your claim.
INSTRUCTIONS: Complete each section in its entirety. Failure to do so may delay processing of your victim compensation claim.
Name of Patient (Last, First, Middle Initial)
CVC Case Number
Social Security Number
Date of Birth
Address
City
State
ZIP Code
Telephone/Cell Number
PATIENT AUTHORIZATION FOR DISCLOSURE AND SIGNATURE
I Hereby Authorize any hospital, physician, surgeon, dentist, medical facility, mental health provider, treatment provider, funeral home or any provider who
rendered services; any employer of the victim; any law enforcement or other state/federal governmental agency; and any insurance company, to furnish North
Dakota Crime Victims Compensation or its representative, confidential information with respect to the incident leading to the victim’s personal injury or death,
and the claim made herewith for compensation. A photocopy of this signed release is as effective and valid as the original.
Provider Name
Telephone Number
Provider Address
City
State
ZIP Code
Provider Name (for more than one provider)
Telephone Number
Provider Address
City
State
ZIP Code
To Disclose Protected Health Information with:
ND DOCR Crime Victims Compensation, PO Box 1898, Bismarck, ND 58502-1898
Phone 701-328-6195, FAX 701-328-6780, email
DOCRcompensation@nd.gov
INFORMATION TO BE RELEASED
Service Dates: From :_____________________ To:_____________________ AND all future records until authorization has been revoked or
expires.
I authorize disclosure of the following protected health care information to the ND DOCR Crime Victims Compensation for purposes to
administer Crime Victims Compensation claim.
alcohol/drug evaluation/assessment
ER records, operative reports
psychological evaluations, reports
treatment/progress reports
test, imaging and lab reports
psychiatric evaluations, reports
results of drug screens
consults, outpatient visit notes
counseling, therapy reports
discharge summary
discharge notes
psychotherapy
This Authorization to Disclose Information Remains in Effect for Two Years From the Date of My Signature or Until This Date:
PATIENT CONSENT
I understand this consent will remain in effect for two years from the date of this form. I understand that I have the right to revoke this authorization, in
writing, at any time. Any information disclosed prior to the termination of this authorization is not a breach of confidentiality. A photocopy of this
authorization is as effective as the original. Unless otherwise agreed in writing, information may be disclosed under this authorization in any form or
medium, including oral, written, or electronic transmission.
Signature of Patient (required)
Date
Signature of Parent/Guardian or Custodian (if needed and Relationship)
Date
Signature of Witness (sign and print)
Date
CHECK
IF
APPLICABLE
-
NOTICE
TO
WHOMEVER
DISCLOSURE
IS
MADE
CONCERNING
ADDICTION
RECORDS
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules
prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written
authorization of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the disclosure of
medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate
or prosecute any alcohol or drug abuse patient.
NOTICE: Except for information subject to 42 CFR Part 2, information disclosed to another entity may potentially be redisclosed, in which case it may not be
protected by state of federal law.
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION – CRIME VICTIMS COMPENSATION
NORTH DAKOTA DEPARTMENT OF CORRECTIONS AND REHABILITATION
SFN 61353 (03-2019)
PRIVACY STATEMENT: Disclosure of the social security number is voluntary and is requested for the purpose of accurate identification. Failure to disclose a
social security number will not affect the disclosure of other information. The DOCR may, however, require that you authorize disclosure of your health
information if needed to make a determination about your claim.
INSTRUCTIONS: Complete each section in its entirety. Failure to do so may delay processing of your victim compensation claim.
Name of Patient (Last, First, Middle Initial)
CVC Case Number
Social Security Number
Date of Birth
Address
City
State
ZIP Code
Telephone/Cell Number
PATIENT AUTHORIZATION FOR DISCLOSURE AND SIGNATURE
I Hereby Authorize any hospital, physician, surgeon, dentist, medical facility, mental health provider, treatment provider, funeral home or any provider who
rendered services; any employer of the victim; any law enforcement or other state/federal governmental agency; and any insurance company, to furnish North
Dakota Crime Victims Compensation or its representative, confidential information with respect to the incident leading to the victim’s personal injury or death,
and the claim made herewith for compensation. A photocopy of this signed release is as effective and valid as the original.
Provider Name
Telephone Number
Provider Address
City
State
ZIP Code
Provider Name (for more than one provider)
Telephone Number
Provider Address
City
State
ZIP Code
To Disclose Protected Health Information with:
ND DOCR Crime Victims Compensation, PO Box 1898, Bismarck, ND 58502-1898
Phone 701-328-6195, FAX 701-328-6780, email
DOCRcompensation@nd.gov
INFORMATION TO BE RELEASED
Service Dates: From :_____________________ To:_____________________ AND all future records until authorization has been revoked or
expires.
I authorize disclosure of the following protected health care information to the ND DOCR Crime Victims Compensation for purposes to
administer Crime Victims Compensation claim.
alcohol/drug evaluation/assessment
ER records, operative reports
psychological evaluations, reports
treatment/progress reports
test, imaging and lab reports
psychiatric evaluations, reports
results of drug screens
consults, outpatient visit notes
counseling, therapy reports
discharge summary
discharge notes
psychotherapy
This Authorization to Disclose Information Remains in Effect for Two Years From the Date of My Signature or Until This Date:
PATIENT CONSENT
I understand this consent will remain in effect for two years from the date of this form. I understand that I have the right to revoke this authorization, in
writing, at any time. Any information disclosed prior to the termination of this authorization is not a breach of confidentiality. A photocopy of this
authorization is as effective as the original. Unless otherwise agreed in writing, information may be disclosed under this authorization in any form or
medium, including oral, written, or electronic transmission.
Signature of Patient (required)
Date
Signature of Parent/Guardian or Custodian (if needed and Relationship)
Date
Signature of Witness (sign and print)
Date
CHECK
IF
APPLICABLE
-
NOTICE
TO
WHOMEVER
DISCLOSURE
IS
MADE
CONCERNING
ADDICTION
RECORDS
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules
prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written
authorization of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the disclosure of
medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate
or prosecute any alcohol or drug abuse patient.
NOTICE: Except for information subject to 42 CFR Part 2, information disclosed to another entity may potentially be redisclosed, in which case it may not be
protected by state of federal law.