Authorize People Kroger Pharmacy Form PDF Details

Managing personal health information requires careful consideration and, often, formal documentation to authorize the release of such private data. The Authorize People Kroger Pharmacy form is a prime example of such documentation, designed to enable individuals to control who has access to their protected health information (PHI). By completing this form, a person explicitly names who can receive and utilize their health details, from personal representatives to specific organizations, clearly stating the scope and purpose of the disclosed information. Importantly, it outlines the individual's right to revoke this authorization at any given time, albeit with the understanding that any previously shared information remains unaffected by this revocation. Further, it reassures that refusal to sign does not impact one's treatment opportunities at the pharmacy, while also acknowledging the potential for the disclosed information to be less protected once it leaves the pharmacy's hands. With a designated expiration date, the authorization ensures that consent is time-bound, offering an additional layer of control over one's PHI. Signing this form also comes with the promise of a copy for personal records, emphasizing transparency and the signer’s autonomy over their health information.

QuestionAnswer
Form NameAuthorize People Kroger Pharmacy Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameskroger release form, kroger pharmacy authorization, kroger pharmacy records request, kroger authorization form

Form Preview Example

KROGER PHARMACY

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

I ____________________________ [Print Name] hereby authorize the use and/or disclosure of my protected health information (“PHI”)

as described in this authorization.

1.Specific person/organization (or class of persons) authorized to provide the information:

___________________________________________________________

2.Specific person/organization (or class of persons) authorized to receive and use the information:

___________________________________________________________

3.Specific description of the information:

___________________________________________________________

4.Specific purpose for the use and/or disclosure of the PHI (list and describe each purpose):

___________________________________________________________

5.I understand that I may revoke this Authorization at any time by notifying Kroger in writing at the Kroger Privacy Office, 1014 Vine St., Cincinnati, OH 45202-1100. I understand that the revocation is only effective after it is received and logged by Kroger. I also understand that any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation.

6.I understand that I may refuse to sign this Authorization and that my refusal to sign will not affect my ability to obtain treatment from the pharmacy.

7.I understand that after this information is disclosed, federal law might not protect it and the recipient might redisclose it .

8.I understand that I am entitled to receive a copy of this authorization.

9.This Authorization expires __________________________________________ [date or event].

________________________________________

__________________

__________________

Signature of Customer or Personal Representative

Date of Birth

Date

Address: _______________________________

_____________________

 

 

Telephone (optional)

 

_______________________________________

 

 

If signed by the patient’s personal representative, the representative warrants that he or she has authority to sign this form on the basis of

(attach a copy of any documentation used to verify authority)

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Part number 1 in completing kroger authorization

2. Once your current task is complete, take the next step – fill out all of these fields - I understand that I am entitled to, This Authorization expires , Telephone optional, Date, Date of Birth, and attach a copy of any documentation with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Part # 2 in filling in kroger authorization

Always be very attentive when filling out Date and attach a copy of any documentation, because this is the section in which most users make some mistakes.

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