2) 24 months, provided the current person or entity can provide a new, valid justification for the use or disclosure, regardless of when the current use or disclosure occurred. 3) 12 months, provided the current person or entity can provide a new, valid justification for the use or disclosure, regardless of when the current use or disclosure occurred. 4) 24 months, provided the current person or entity can provide a new, valid justification for the use or disclosure, regardless of when the current use or disclosure occurred. I authorize persons or entities other than the above persons or entities to access and use this information in the following settings: 1) medical billing or medical record; 2) insurance claims processing or medical billing; 3) legal compliance; 4) data analysis; and 5) research. I understand that this authorization does not authorize the storage, processing, distribution, or use of this personally identifiable health information by a person or entity other than the provider. Furthermore, I understand that this authorization does not permit a person or entity other than the provider to: disclose my name and other personally identifiable information if the information was obtained about me without my knowledge; or to copy or store information about me which has been disclosed to the provider. Furthermore, I understand that my continued use or disclosure of this information is voluntary and that my continued disclosure of this information may cause me to lose rights or entitlements which I may have. Furthermore, I understand that a person or entity other than the provider may not use this information other than in accordance with this authorization. Furthermore, I agree that the provider may disclose this health information for a legitimate purpose, subject to the restrictions set forth in this authorization as long as the person or entity acting on the provider's behalf is acting in good faith. Furthermore, I do not want this information used by a person or entity other than the provider in the following settings: 1) health or social services or insurance, 2) legal, 3) public health, 4) patient care, 5) health research, or 6) any other purpose related to my health or the health of others. Furthermore, I understand that if my personally identifiable health information is breached, my use rights may be impacted, this authorization may be terminated or suspended or that my continued use of the provider's services may require me to consent to further use, disclosure or other changes.
NH DHHS GM 509b free printable template
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FORM GM 509b Authorization Form For the Use and Disclosure of Individually Identifiable Health Information I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be redisclosed and no longer protected by federal privacy regulations. This authorization expires on Persons/organizations authorized to use and/or disclose the information Specific description of...
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