Paratransit Access Line

Disclosure Form

 

Schedules Effective
June 22, 2008
Through Augsut 30, 2008

 

AUTHORIZATION TO DISCLOSE
PROTECTED HEALTH INFORMATION

 

I hereby authorize (Insert Professional’s Name) __________________________________ entrusted with handling medical records to disclose to the NFT Metro all of the protected health information relating to (the applicant)________________________________ to fully and accurately complete the NFT Metro Application for Paratransit Service which application will be used by NFT Metro for determining whether the Applicant is eligible for Paratransit Access Line. 

This authorization shall remain in effect until the Applicant’s eligibility for Pal service is finally determined or sixty days, whichever is shorter.

I acknowledge that I have the right to revoke this authorization at any time by sending written notification to the Health Care Professional that would be completing Part II of this application.  I understand that the revocation of this authorization is not effective to the extent that the Health Care Professional has relied upon it for the use or disclosure of the Protected Health Information prior to receiving my written revocation notice.

I understand that any Protected Health Information disclosed pursuant to this Authorization to an individual or entity that is not covered by the state and federal privacy laws and regulations may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.

Date ____________________

Signature of Patient (or Personal Representative)_______________________________________

Important:  If a Personal Representative signed above, please describe his or her relationship with the patient (e.g., parent) or other authority to sign this form on behalf of the patient (e.g., legal guardian): _____________________________________________

 

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