Kroger Pharmacy Authorization for Release of Health Information at a glance
What it is: Kroger Pharmacy Authorization for Release of Health Information: I hereby authorize the use and/or disclosure of my protected health information (“PHI”) as described in this authorization.
Who signs: 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).
A filled-in Kroger Pharmacy Authorization for Release of Health Information example: a customer lets a clinic send records to her daughter
How to fill out Kroger Pharmacy Authorization for Release of Health Information, box by box
I, Print Name
Print Name on the line after I.
1 to 4: the information, who provides it, who receives it and why
In 1, write the specific person/organization (or class of persons) authorized to provide the information.
In 2, write the specific person/organization (or class of persons) authorized to receive and use the information.
In 3, write the specific description of the information.
In 4, write the specific purpose for the use and/or disclosure of the PHI (list and describe each purpose).
9: This Authorization expires
In 9, write the date or event on which this Authorization expires.
Signature, Date of Birth and Date
Sign on the Signature of Customer or Personal Representative line, then enter the Date of Birth and the Date.
Address and Telephone (optional)
Enter the Address; the Telephone is optional.
More rules for Kroger Pharmacy Authorization for Release of Health Information
You may revoke this Authorization at any time by notifying Kroger in writing at the Kroger Privacy Office, 1014 Vine St., Cincinnati, OH 45202-1100.
The revocation is only effective after it is received and logged by Kroger; any use or disclosure made prior to the revocation under this authorization will not be affected by a revocation.
You may refuse to sign this Authorization, and your refusal to sign will not affect your ability to obtain treatment from the pharmacy.
After this information is disclosed, federal law might not protect it and the recipient might redisclose it.
You are entitled to receive a copy of this authorization.
Sources
[1] Kroger Pharmacy Authorization for Release of Health Information (served file; no issuer file published) (the Official source link on this page).