Hippa Fidelis Form PDF Details

In today's healthcare landscape, protecting patient information while ensuring its accessibility to authorized individuals is paramount. The HIPAA Privacy Release Form, such as the one provided by Fidelis Care New York, stands as a cornerstone in navigating the balance between confidentiality and requisite disclosure. It empowers individuals by allowing them to authorize the use and disclosure of their protected health information (PHI) to specified parties. This authorization spans a range of healthcare information, covering everything from mental health to treatment for alcohol or drug abuse, and can be applied to past, present, and future healthcare periods. The form outlines the extent of information to be shared, whether it's the complete health record or select parts, and details the purpose behind the disclosure, be it for medical treatment, billing, or other specified reasons. Importantly, it assures users that their consent is voluntary and that their healthcare services will not be affected by their decision on authorization. Additionally, it lays out the parameters for the effective period of this authorization and provides instructions for its revocation, emphasizing the control individuals have over their health information. Furthermore, it acknowledges that once the information is disclosed, it might not be protected under federal or state law to the same degree. Through its comprehensive approach, the HIPAA Privacy Release Form by Fidelis Care New York exemplifies the meticulous care taken to respect patient autonomy while accommodating the operational needs of the healthcare system.

QuestionAnswer
Form NameHippa Fidelis Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfidelis care hipaa privacy release form, form fidelis care form, fidelis care 1095 b form, hipaa fidelis care

Form Preview Example

2. Effective Period

HIPAA Privacy Release Form

Authorization for Use of Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.

Parts 160 and 164)

Name: ____________________________________

Member ID: __________________________________

Birthdate: ________ /________ / ________

 

1. Authorization

 

a. I authorize Fidelis Care New York to use and disclose the protected health information described below to

__________________________________________________ (individual seeking the information).

Authorization to discuss health care information: By initialing here _________ I

authorize Fidelis Care to discuss my health information with the entity or person(s) listed below:

This authorization for release of information covers the period of healthcare from:

a. ☐ _______________ to _______________ ** OR ** b. ☐ all past, present, and future periods.

3. Extent of Authorization

a. ☐ I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse).

** OR **

b. ☐ I authorize the release of my complete health record with the exception of the following information:

☐Mental health records ☐ Communicable Diseases (including HIV and AIDS)

☐Alcohol/drug abuse treatment ☐ Other (please specify): _____________________________

4.This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5.This authorization shall be in force and effect until _______________________ (date or event), at which time this authorization expires.

6.I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

7.I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign authorization.

8.I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of patient or personal representative:

Printed name of patient or personal representative and his or her relationship to patient:

Date:

__________ / __________ / __________

Mail the form and documents to:

Or fax them to:

Fidelis Care Member Services 95-25 Queens Blvd., 7th Floor Rego Park, NY 11374

(718) 896-6832

Law firms, record retrieval agencies, and third party insurance entities requesting a claims payment report for litigation or subrogation purposes, please note: you must submit a notarized authorization to receive records.

How to Edit Hippa Fidelis Form Online for Free

fidelis care hipaa privacy release form can be completed without any problem. Just make use of FormsPal PDF editor to complete the task right away. To make our editor better and simpler to utilize, we continuously design new features, bearing in mind suggestions coming from our users. Here's what you'd want to do to begin:

Step 1: Click the orange "Get Form" button above. It is going to open up our editor so that you could start completing your form.

Step 2: The tool gives you the capability to work with your PDF form in a range of ways. Transform it by writing any text, adjust what is already in the PDF, and add a signature - all at your fingertips!

With regards to the blank fields of this particular form, this is what you should do:

1. It is critical to fill out the fidelis care hipaa privacy release form correctly, therefore be mindful when filling in the segments including all of these fields:

Step # 1 of filling in fidelis form for long term care

2. Now that this segment is done, you have to put in the required particulars in Effective Period This, following information, and or drug abuse so that you can proceed to the 3rd step.

Part no. 2 in filling out fidelis form for long term care

3. This next stage will be easy - fill in every one of the fields in Mental health records, Alcoholdrug abuse treatment, This medical information may be, This authorization shall be in, I understand that I have the, and I understand that my treatment to complete this segment.

fidelis form for long term care completion process explained (portion 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - Signature of patient or personal, Printed name of patient or, Date, Mail the form and documents to, Fidelis Care Member Services, Or fax them to, and Law firms record retrieval - to proceed further in your process!

fidelis form for long term care writing process detailed (stage 4)

People generally make errors while filling out Law firms record retrieval in this part. Be sure to double-check everything you type in right here.

Step 3: After rereading your fields and details, hit "Done" and you're all set! Create a 7-day free trial account at FormsPal and get direct access to fidelis care hipaa privacy release form - download, email, or change in your FormsPal account. With FormsPal, it is simple to fill out documents without being concerned about information breaches or entries being shared. Our secure system ensures that your private data is kept safely.

Hippa Fidelis Form isn’t the one you’re looking for?

Related Documents