Forms PTO AIA 04, Authorization to Release Protected Health Information, and SSA 832 are both release of information forms used by organizations to disclose protected health information (PHI) to a specified third party. Forms PTO AIA 04 is for disclosure to individuals or organizations other than the patient, while SSA 832 is for disclosure to the Social Security Administration. The authorization must meet specific criteria in order to be valid, and both forms include necessary language for the provider and the patient. Knowing when and how to use these forms can help safeguard PHI while ensuring that patients receive the care they need. What is the difference between Forms PTO AIA 04 and SSA 832? When do you need each form? How can knowing this information help safeguard PHI? Stay tuned as we break it all down below!
| Question | Answer |
|---|---|
| Form Name | Form Pto Aia 04 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | Substitute Statement in Lieu of Oath or Declaration for Plant Patent Application (PTO AIA 04) reissue application with substitute statement instead of inventor declaration form |
Doc Code: Oath |
PTO/AIA/04 |
Document Description: Oath or declaration filed |
Approved for use through 01/31/2014. OMB |
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U.S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE |
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
SUBSTITUTE STATEMENT IN LIEU OF AN OATH OR DECLARATION FOR
PLANT PATENT APPLICATION (35 U.S.C. 115(d) AND 37 CFR 1.64)
Title of
Invention
This statement is directed to: |
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The attached application, |
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OR |
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United States application number |
filed on |
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LEGAL NAME of inventor to whom this substitute statement applies:
(E.g., Given Name (first and middle (if any)) and Family Name or Surname)
Residence (except for a deceased or legally incapacitated inventor):
City |
State |
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Country |
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Mailing Address (except for a deceased or legally incapacitated inventor): |
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City |
State |
Zip |
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Country |
I have asexually reproduced the plant to which this application applies;
The plant was found in cultivated area (check this box for newly found plant only)
I believe the
The
I hereby acknowledge that any willful false statement made in this declaration is punishable under 18 U.S.C. 1001 by fine or imprisonment of not more than five (5) years, or both.
Relationship to the inventor to whom this substituite statement applies:
Legal Representative (for deceased or legally incapacitated inventor only),
Assignee,
Person to whom the inventor is under an obligation to assign,
Person who otherwise shows a sufficient proprietary interest in the matter (petition under 37 CFR 1.46 is required), or
Joint Inventor.
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PTO/AIA/04
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
SUBSTITUTE STATEMENT
Circumstances permitting executive of this substitute statement:
Inventor is deceased,
Inventor is under legal incapacity,
Inventor cannot be found or reached after diligent effort, or
Inventor has refused to execute the oath or declaration under 37 CFR 1.63.
If there are joint inventors, please check the appropriate box below:
An application data sheet under 37 CFR 1.76 (PTO/SB/14 or equivalent) naming the entire inventive entity has been or is currently submitted.
OR
An application data sheet under 37 CFR 1.76 (PTO/SB/14 or equivalent) has not been submitted. Thus, a Substitute Statement Supplemental Sheet (PTO/AIA/11 or equivalent) naming the entire inventive entity and providing inventor information is attached. See 37 CFR 1.64(b).
WARNING:
Petitioner/applicant is cautioned to avoid submitting personal information in documents filed in a patent application that may contribute to identity theft. Personal information such as social security numbers, bank account numbers, or credit card numbers (other than a check or credit card authorization form
PERSON EXECUTING THIS SUBSTITUTE STATEMENT:
Name:
Date (Optional):
Signature:
Residence (unless provided in an application data sheet, PTO/SB/14 or equivalent):
City
State
Country
Mailing Address (unless provided in an application data sheet, PTO/SB/14 or equivalent)
City
State
Zip
Country
Note: Use an additional PTO/AIA/02 form for each inventor who is deceased, legally incapacitated, cannot be found or reached after diligent effort, or has refused to execute the oath or declaration under 37 CFR 1.63.
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