Form Hs 2939 PDF Details

Form HS 2939 is a document that tax preparers use to claim the child and dependent care credit. This form can be used to claim expenses for qualifying children and dependents who are minors or who are physically or mentally incapable of self-care. There are a number of rules and requirements that must be met in order to claim the child and dependent care credit, so it's important to understand what qualifies before filing this form. In this blog post, we'll take a closer look at Form HS2939 and provide some tips on how to complete it correctly.

QuestionAnswer
Form NameForm Hs 2939
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshipaa compliant medical authorization form for tn residents, tn release medical, tennessee hipaa release, tennessee form hipaa release

Form Preview Example

TENNESSEE DEPARTMENT OF HUMAN SERVICES

HIPAA AUTHORIZATION FOR RELEASE OF MEDICAL/HEALTH INFORMATION

TO 3RD PARTY

Information will be released for:

 

Date:

Identify Signer:

 

 

PRINT NAME►

 

 

Self

Parent of minor

Guardian

 

 

 

 

Other authorized representative (explain) *Proof of legal authorization

Street Address

 

 

may be required.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Parent/guardian sign here if two

 

 

 

 

signatures required by State law)

 

 

 

 

 

 

 

Phone Number (with area code)

City

 

 

State

 

Zip

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I give permission for the following medical/health records about me to be released by the Tennessee Department of Human Services (TDHS) and its authorized agents/contractors to the persons/organizations and for the purposes described below:

Specific Description of medical/health information to be provided *Additional approval required for certain records)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

*TDHS can also release drug or alcohol treatment/referral records: Yes:_____ No:____

*TDHS can also release HIV/AIDS test/treatment records: Yes _____ No:_____

TDHS can release my medical/health information to the following persons/organizations:

___________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

My medical/health records will be used for the following purposes: ___________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

For the medical/health records I have given permission to be disclosed, TDHS can talk to, or give copies of my medical/health records to any of the person/organizations I have permitted and can give this information by paper, fax, computer or electronic copies of those records.

YOU DO NOT HAVE TO SIGN THIS FORM. I understand that my eligibility for benefits or services from the Tennessee Department of Human Services will not be affected if I do not sign this form.

I will get a copy of this form after I sign it. I can ask TDHS to let me see a copy of the information it sends after I sign this form.

This permission is good for 12 months from the date I sign this form, unless I take back my permission sooner.

You have the right to withdraw your permission at any time. You cannot take back information that has been given to other persons/organizations before you take back your permission and it will not affect any actions taken before you take back your permission.

To take back your permission to let us give your medical/health records to other persons/organizations, you can write TDHS in your county, or write the persons/organizations that you have said we can give your information to. I understand that the person or organization that I have given permission to get my medical/health information may not be required by law to protect that information under federal or state law or regulations.

Ask TDHS to explain if you have questions about what information was given to any person or organization.

Signature of Person or Person’s Authorized Representative: ___________________________ Date:_________________

This authorization was developed to comply with the provisions regarding disclosure of medical/health information under P. L. 104-191 (“HIPAA”); 45 Code of Federal Regulations parts 160 and 164; 42 U.S. Code Section 290dd-2; 42 CFR part 2.31; 38 U.S. Code section 7332 and T.C.A § 68-10-113.

HS-2939 (Revised 01/2007) HIPAA Authorization for Release of Medical/Health Information By TDHS to 3rd Party (English)

How to Edit Form Hs 2939 Online for Free

tn release health information can be completed very easily. Just make use of FormsPal PDF editing tool to perform the job promptly. Our professional team is continuously endeavoring to develop the editor and ensure it is much better for people with its cutting-edge features. Enjoy an ever-evolving experience today! With some simple steps, it is possible to start your PDF editing:

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With regards to the fields of this precise form, here's what you should consider:

1. First, when completing the tn release health information, start in the area that includes the following fields:

How one can fill in tennessee hipaa authorization part 1

2. After filling out this section, go on to the subsequent step and enter all required particulars in these fields - I give permission for the, I will get a copy of this form, To take back your permission to, Ask TDHS to explain if you have, and Signature of Person or Persons.

Simple tips to fill out tennessee hipaa authorization part 2

It is possible to make an error when filling in the Signature of Person or Persons, for that reason ensure that you take another look prior to when you send it in.

Step 3: Before submitting your document, double-check that form fields have been filled in properly. Once you’re satisfied with it, press “Done." Join us now and easily gain access to tn release health information, available for downloading. All adjustments you make are kept , meaning you can edit the document at a later stage when necessary. Whenever you work with FormsPal, you can complete documents without stressing about database breaches or data entries being distributed. Our secure platform ensures that your personal information is maintained safely.