Form Mr 10 56 PDF Details

In order to begin discussing Form Mr 10 56, it is important to understand what an election is. An election is a process by which eligible citizens cast ballots to choose individuals to represent them in governing institutions. The first step in the election process is nominating candidates. A nomination occurs when someone puts their name forward as a candidate for office. In this post, we will be discussing Form Mr 10 56, which is the form used to nominate candidates for office in Alberta. More specifically, we will be discussing who can nominate candidates and how nominations are confirmed. Stay tuned for our next post, where we will discuss the voting process!

QuestionAnswer
Form NameForm Mr 10 56
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinova authorization form, cats authorization release pdf, inova authorization release information, inova release health information form

Form Preview Example

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

Inova Comprehensive Addiction Treatment Services (CATS)

3300 Gallows Road, Falls Church, Virginia 22042

 

 

 

 

 

 

Central Accessrzoj) 776-7777

 

Fax (703) 776-7799

 

 

Patient

Full Name

 

 

 

 

 

Medical Record

#

 

Street

 

 

 

 

 

 

 

City

 

State

Zip

Telephone

Numbers: (home)

 

 

 

 

 

(cell)

 

 

 

Patient's

 

Date

of Birth

 

 

 

 

Dates

of Service

 

 

 

I,

 

 

 

 

 

 

 

authorize

Inova Comprehensive

Addiction

Treatment

Services

to release I disclose

the following information

TO:

 

 

 

 

 

Name or Person or Entity to

receive information

 

 

 

Relationship

to

Patient

 

Street

 

 

 

 

 

 

 

City

 

State

Zip

Telephone

Number

 

 

 

 

Fax Number

 

 

 

Information to be released I disclosed:

 

 

 

 

 

 

 

o Admission to

the program

 

 

 

 

 

o Diagnostic

lab work

 

o

Assessment

and Diagnosis

 

(Axis 1-5)

 

 

 

o Program

participation

 

o

Compliance

with treatment

 

recommendations

and referrals

 

o Financial

documentation

o

Results

of drug screens and

breathalyzer tests

 

 

 

o Treatment

plan goals

and objectives

o Progress towards accomplishing treatment plan goals and objectives

 

 

 

DOther

 

 

 

 

 

 

 

_

 

 

 

 

For the purpose of: o Service coordination

o Participation in family program

o Reports to probation officer or attorney

o Emergency

Contact

o

Completion of family interview

o

Other

_

I understand that my records are protected under Federal confidentiality regulations (42 CFR Part 2). Any person or entity receiving my information will be informed that re-disclosure is not permitted without my consent or otherwise permitted by the regulations. I also understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance upon it. I understand that written notification is preferred, but not required to revoke this consent and should be forwarded to the address at the top of this form. I understand that in any event this consent automatically expires 90 days from the date of signature. This consent includes information placed in my record after the date of the signature below.

I understand that Inova Comprehensive Addiction Treatment Services (CATS) may not condition my treatment on my decision to sign this authorization.

Signature of Patient or Authorized

Representative

Date (Authorization

expires 90 days after signature)

Printed Name of Authorized

Representative

(as applicable)

Relationship to Patient

Addressograph

INOVA COMPREHENSIVE ADDICTION TREATMENT SERVICES

Authorization to Release Protected Health Information

MR-10-S6(REV 03/12)

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