Form 143444 PDF Details

The form 143444, integral to the operations of the Palo Alto Medical Foundation, serves a pivotal role in the authorization and disclosure of health information, adhering to stringent state and federal laws. Situated in Palo Alto, California, this document is an essential tool for ensuring that patients’ medical records, including laboratory, imaging reports, and immunizations, are shared in compliance with their consent. It requires a patient or their personal representative to provide a signature, establishing a clear relationship with the patient and dictating the terms under which personal health information can be released to specified individuals or organizations. Notably, the form includes provisions for the disclosure of sensitive information, such as HIV status, mental health, and substance use details, subject to the patient’s initial consent. Additionally, it acknowledges the limitations of privacy protection once the information leaves the state of California. The authorization remains valid for a specified duration, offering patients the option to revoke consent at any time, thereby exemplifying a commitment to patient autonomy and privacy. This detailed process ensures that all parties are aware of their rights and responsibilities, emphasizing the foundation’s dedication to patient care, privacy, and the lawful management of personal health data.

QuestionAnswer
Form NameForm 143444
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namespamf from 143444, palo alto medical foundation prior authorization request form, form 143444 printable, pamf authorization form

Form Preview Example

Patient/Personal Representative Signature
Relationship to Patient
DISTRIBUTION White - Record; Yellow - Copy

PALO ALTO MEDICAL FOUNDATION

Palo Alto Medical Clinic, 795 El Camino Real, Palo Alto, CA 94301

A Sutter Health Affiliate

(650) 853-4745, (650) 853-6093 Fax

 

MUST COMPLETE FORM IN ORDER TO AVOID ANY DELAYS

PAMF #

 

 

 

 

 

 

 

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

 

 

 

This authorization for use or disclosure of my health information is required by state and federal law.

PATIENT'S NAME

 

 

 

 

DOB:

 

 

 

 

 

 

 

 

 

 

LAST

FIRST

 

MI

 

 

 

 

 

Daytime Telephone Number

 

 

Social Security No:

 

I HEREBY AUTHORIZE THE USE OR DISCLOSURE OF MY HEALTH INFORMATION

(NAME OF PERSON OR ORGANIZATION RELEASING INFORMATION)

STREET ADDRESS

CITY

STATE

ZIP CODE

TO RELEASE MY HEALTH INFORMATION TO:

NAME OF PERSON OR ORGANIZATION RECEIVING INFORMATION

STREET ADDRESS

CITY

STAFF

ZIP CODE

 

 

 

 

 

 

THIS AUTHORIZATION APPLIES TO THE FOLLOWING INFORMATION:

 

 

 

 

 

 

 

All records

 

Lab

 

Imaging Reports

 

 

Immunizations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

THE RECIPIENT MAY USE MY HEALTH INFORMATION ONLY FOR THE FOLLOWING PURPOSE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(PLEASE SPECIFY

 

 

 

 

 

 

 

 

 

 

 

A SPECIFIC AUTHORIZATION IS REQUIRED TO RELEASE INFORMATION REGARDING THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

YES

NO

INITIALS

HIV Information

Drug/Alcohol Information

Mental Health Information

Restrictions: California law prohibits the recipient from making further disclosure of your health information unless the recipient obtains another authorization from you or unless the disclosure is required or permitted by law This protection does not extend to recipients outside the state of California.

This authorization shall be valid untilPlease indicate a date after which no infor-

mation can be released. If no date is given, authorization is valid for 90 days only.

I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment.

I may revoke this authorization at any time, in writing. The revocation must be signed by me or on my behalf and sent to the address on the top of this form. The revocation is effective upon receipt but will have no impact on uses or disclosures made while the authorization was valid.

I HAVE A RIGHT TO A COPY OF THIS AUTHORIZATION.

Copy Requested:

 

Yes

 

No Copy Received:

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Signature

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FORM 143444 (DECEMBER 2003)

How to Edit Form 143444 Online for Free

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1. First, once completing the pamf online, begin with the page with the following fields:

Completing segment 1 of pamf referral form

2. The third part is to submit these fields: STREET ADDRESS, CITY, STAFF, ZIP CODE, THIS AUTHORIZATION APPLIES TO THE, All records Other, Lab, Imaging Reports, Immunizations, THE RECIPIENT MAY USE MY HEALTH, PLEASE SPECIFY, A SPECIFIC AUTHORIZATION IS, YES, INITIALS, and HIV Information DrugAlcohol.

Writing section 2 in pamf referral form

3. In this particular part, look at I may refuse to sign this, I HAVE A RIGHT TO A COPY OF THIS, Copy Requested, Yes, No Copy Received, Yes, Patient Signature, PatientPersonal Representative, Relationship to Patient, Date, and FORM December. Each of these must be taken care of with highest precision.

pamf referral form completion process outlined (step 3)

In terms of FORM December and Date, be sure that you do everything right in this section. The two of these are the key fields in this form.

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