Are you an individual interested in a new healthcare provider, or perhaps a medical professional looking for information on HIPAA Form F1? Either way, you're in the right place! In this blog post, we will be taking an in-depth look at the HIPAA Form F1. We'll discuss what exactly it is, how to get one and complete it correctly as well as some of its important implications. With vital information such as records privacy and your health history at stake, understanding all aspects of the form should be priority number one! Let's dive into all that HIPAA Form F1 has to offer!
Question | Answer |
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Form Name | Hipaa Form F1 |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | 2011, 210-B, Ventura, HIV |
HIPAA Form F1 Rev. 9/04 |
Page 1 of 2 |
Ventura County Health Care Plan
INSTRUCTIONS: You must complete all information below. If incomplete, this authorization will be returned. If you have any questions or need assistance completing this form, please contact Customer Service at (805)
Member/Patient Name: |
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Date of Birth: |
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VCHCP Member Number: |
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Telephone: |
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Address: |
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State |
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Number and Street |
City |
Zip Code |
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Section 2 Important Information about this Authorization to Release Information
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■Voluntary
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■Psychotherapy
Please check one of the boxes below. If you do not select anything, VCHCP will release General Health Care Information as described below.
General Health Care
Other— (Please be specific. You may identify information by date of service, name of provider, or specific diagnosis):
2011 LCK
Section 4. |
Authorized Person(s) – authorization may only be granted to an individual, not to an organization. |
Provide the information below for each person that is authorized to receive your protected health information identified above. Please include a complete address and specify the relationship to the patient. Please print.
Name: |
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Name: |
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Organization (if applicable): |
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Organization (if applicable): |
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Address: |
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Address: |
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Street or Post Office Box |
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Street or Post Office Box |
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City |
State |
Zip Code |
City |
State |
Zip Code |
Telephone: |
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Telephone: |
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Relationship to Patient: |
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Relationship to Patient: |
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i.e. mother, attorney , neighbor, friend, benefits administrator |
i.e. mother, attorney , neighbor, |
friend, |
employer |
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representative |
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Section 5. |
Expiration |
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Unless revoked, this authorization is valid from the date of my signature until the date I am no longer insured by VCHCP or upon the date written below (if any), whichever occurs first. This authorization will automatically terminate upon my death.
This authorization shall terminate on (specify date, if applicable). *
*Any authorization concerning a minor under the age of twelve will automatically expire upon the minor’s tw elfth birthday. The minor may complete an authorization upon such expiration.
Section 6. |
Revocation |
I understand that I may revoke this authorization at any time by mailing WRITTEN notice of my revocation to VCHCP ATTN: Privacy Officer at 2200 E. Gonzales Rd.
Section 7. Signature
I have had full opportunity to read and consider the contents of this authorization, and I confirm that the contents are consistent with my direction to VCHCP. I understand that, by signing this form, I am confirming my authorization that VCHCP, its employees, officers and agents including, but not limited to, Express Scripts and OptumHealth Behavioral Solutions may use and/or disclose the protected health information described in this form to the authorized person(s) named
above. |
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Member/Patient Signature**: |
Date: |
**If the Member/Patient is a minor aged 12 through 18, he/she must authorize the release of certain protected health information even if a parent or legal guardian is requesting the information. If the authorized person is anyone other than the parent, and the authorization is for information other than treatment for mental health, substance abuse and/or sexually transmitted disease, the parent must also sign this authorization. The parent should sign as a personal representative, below.
If you are a personal representative (Parent, Legal Guardian, agent acting under a Durable Power of Attorney for Health Care, or Executor or Administrator of Estate) signing on behalf of the Member/Patient, complete the following and attach documentation (if applicable) supporting such personal representation:
Personal Representative’s Name:
Relationship to Member/Patient or Authority to act as Personal Representative:
Please keep a copy of this document for your records and mail the completed Authorization to VCHCP at the address shown above. Or fax to (805)
2011 LCK