In today's world, where the protection of personal and health information is paramount, the State Form 54584 stands out as a crucial document. This form, officially titled "Authorization for Disclosure of Personal and Health Information" and issued by the Family and Social Services Administration/Division of Disability and Rehabilitative Services (DDRS), serves a vital function. Its primary purpose is to enable individuals to grant permission for the disclosure of their personal and potentially sensitive health information to parties outside the DDRS, ensuring a continued protection of their privacy under the stringent guidelines set by state and federal laws. Completing the form requires detailed input from the individual, such as personal identification information, the type of details to be disclosed, the purpose of the disclosure, and specifics about the individuals or organizations authorized to receive the information. This form also includes an expiration clause, offering options on how and when the authorization ceases to be effective, alongside a provision for the individual to revoke the authorization at any point. Furthermore, it underlines the potential of the disclosed information becoming unprotected by privacy laws once it leaves the DDRS, thereby cautioning the individual of the risks involved. The form is comprehensive, demanding the signee to affirm understanding and acceptance of all conditions through their signature, thereby making it a significant document for those navigating the interface of personal rights and health information disclosure.
| Question | Answer |
|---|---|
| Form Name | State Form 54584 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 54584 state form 54584 |
AUTHORIZATION FOR DISCLOSURE OF
PERSONAL AND HEALTH INFORMATION - DDRS
State Form 54584
FAMILY AND SOCIAL SERVICES ADMINISTRATION / DIVISION OF DISABILITY AND REHABILITATIVE SERVICES
Purpose
For you to authorize the disclosure of your personal information, which may include health information, to persons or organizations
outside of the Division of Disability & Rehabilitative Services (DDRS)our privacy is protected by state and federal pri |
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lawss such, we need your eplicit permission to mae the reuested disclos |
urelease complete each section of this form |
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Your Name and Identatnormat |
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Name |
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Address |
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Telephone ( |
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Date of Birth |
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Last 4 Digits of Social Security # |
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t personaormatormate e to d |
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lease describe the type of information we are allowed to dis closefor eample, your contact information, your beneits st |
atus, |
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your medical condition, your healthcare payment status and history, or “as reuested by the authorized personorganizati |
on” |
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t ose oeed de oour personaormat
lease describe the purpose for the disclosure (eg, assis tance with obtaining or using DDRS beneitsservices, legal assis tance, the person is involved in my use of DDRS beneitsservices, or simply “at my reuest ”)
To e e auted to dour personaormat
lease state the names of the individuals or organizations, including con tact information
If the personal information to be disclosed is identiied “as requested by the authorized person/organization”, then we will rely on them to identify what information is to be disclosed when receiving their request for disclosure; we will also rely on them to specify the minimum amount of personal information, including health information, that is reasonably necessary to accomplish the purpose of the request
oam areas are ou auto dour personaormat
ureau of hild Development Services (DS) |
ureau of Developmental Disabilities Services (DDS ) |
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ureau of uality mprovement Services (S) |
ther |
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Eatte or Eent
his authorization will automatically epire sity () cal endar days from the date you sign it ou may specify an earlier or later epiration date, or you may specify an event upon which th is authorization will epire (eg, “when my concern has been addressed”)lease select one of the following three
llow to automatically epire in sity () calendar days |
pire on this date (month, day and year) |
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pire on this event |
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Rt to Reoe
ou have the right to revoe this authorization at any time ou may revoe this authorization by giving wri tten notice, including email notice, to the DDRS contact below ny discl osures of your personal information, including health information, which we may have made under this authorization prior to revocation will not be afected (they were made while this authorization was still in efect)
Furte
nce we disclose your personal information, includi ng health information, to the above personsorganiz ations, the information may no longer be protected under state or federal privacy lawse cannot control what these personsorganiza tions do with your information
Sture
ving had full opportunity to read and consider the contents of this authoriza tion, including my rights and the riss of fur ther disclosure as described above, am authorizing DDRS to di sclose my personal information, including health information, to the persons or organizations have identiied aboveunderst and DDRS will disclose only that information which is neces sary to accomplish the stated purpose of the disclosurehe i nformation disclosed will be limited to the minimum necessary
also understand that am under no obligation to sign this auth |
orization also understand that the services and beneits |
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provided to me by or through DDRS will not be afected whether or not ign this form |
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Signature |
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Date |
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If this authorization is signed by an individual’s personal representative on behalf of the individual, please complete the following
Personal Representative’s Name
Contact Information telephone no
Relationship to the Individual
It is the policy of to verify that an individu |
al’s authorized representative is identiied as such in our iles prior to acting on this authorization |
You will be provided with a copy of this authorization after you sign it.
Contat Inormat
For uestions about this authorization or to revoe this authorizatio n prior to the epiration date or event, contact
he Division of Disability and Rehabilitative Services ashington, Room, S
ndianapolis,
oll Freer mailDDSelpfssagov