Chesterfield Details

If you've been following the news lately, you know that the Trump administration has proposed some major changes to the tax code. One of these proposed changes is a new Form Sl 0427, which would be used to report your foreign assets. This change could have a big impact on taxpayers who hold assets in foreign countries, so it's important to understand how it works and what steps you need to take to prepare for it. In this blog post, we'll break down all you need to know about Form Sl 0427 and how it will affect taxpayers.

In the listing, there's some information concerning the form sl 0427. There, you'll obtain the information regarding the PDF you would like to fill out, like the likely time for you to complete it and other particulars.

QuestionAnswer
Form NameForm Sl 0427
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshipaa certification form, specify, HIV, Lukes

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION FOR USE AND DISCLOSURE OF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROTECTED HEALTH INFORMATION (PHI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

Date of Birth:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please print

 

 

 

 

Social Security Number:

 

 

 

Date of Service:

 

 

Purpose of Request:

 

 

 

 

 

 

 

 

I,

 

 

hereby authorize St. Luke’s Hospital to release my medical records to:

Name of Person/Organization

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

I specifically authorize the use and disclosure of the following:

 

 

 

 

£ Complete medical record(s)

 

OR £ Discharge Summary

£ Progress Notes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

£ History & Physical Examination

£ Laboratory Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

£ Consultation Reports

£ Radiology Reports

£Photographs, videotapes, digital or other images

£Other (please specify):

The information to be used or disclosed pursuant to this authorization may include information relating to: (1) AIDS or HIV infection; (2) treatment of drug or alcohol use; or (3) mental or behavioral health or psychiatric care.

Please DO NOT RELEASE any information, that has been checked below, if it appears in the record.

£ AlcoholAbuse

£ Drug Abuse

£ Psychological / Psychiatric conditions

£ AIDS / HIV results

I may revoke this authorization in writing at any time. I understand that such revocation will not have any effect on the information already used or disclosed by St. Luke’s Hospital before receiving my written notice of revocation. Unless earlier revoked, this Authorization will expire one year from the date it was signed or otherwise specified. I may request to inspect or copy the information that the hospital intends to disclose. I may refuse to sign this Authorization. St. Luke’s Hospital does not require you to sign the authorization to receive treatment. Once release of this information is made to the above named person/organization, my information may be subject to re-disclosure by the recipient.

St. Luke’s Hospital may assess appropriate and reasonable fees for the copying of such information if I am requesting information for myself or for a third party. Such fees will comply with state and federal laws.

I have read the above information and authorize St. Luke’s Hospital to disclose the identified information to the person/ organization and for the purpose described herein. I understand that, by signing this document, I release and discharge St. Luke’s Hospital from any liability and will hold St. Luke’s Hospital harmless for any release made pursuant to the Authorization.

Signature:Date:

Relationship to patient:

AUTHORIZATION FOR USE AND DISCLOSURE OF

PROTECTED HEALTH INFORMATION (PHI)

Page 1 of 1

St. Luke’s Hospital

232 S. Woods Mill Road Chesterfield, MO 63017

Form No. SL-0427

Consents TAB

Rev. 04/03

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