Get Form Gm 509b Nh

FORM GM 509b Authorization Form For the Use and Disclosure of Individually Identifiable Health Information I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be redisclosed and no longer protected by federal privacy regulations. This authorization expires on Persons/organizations authorized to use and/or disclose the information Specific description of information that may be used/disclosed The information will be used/disclosed for the following purposes I understand that this authorization is voluntary and that I may refuse to sign this authorization* I understand that the Department will not condition treatment payment or enrollment in a health plan based on this authorization* I understand that I may revoke this authorization at any time by notifying the Department in writing. However the revocation will not be valid if a* The Department has taken action in reliance on this authorization or b. If this authorization is obtained as a condition for obtaining insurance coverage other law provides the insurer with the right to contest a claim under the policy or the policy itself* Please sign below. Signature Date Printed Name Notary Name Seal If the above signature is that of a patient representative please attach the appropriate legal documentation* For Department Use Only Signature /Title State of New Hampshire Department of Health and Human Services Office of Program Support Compliance Unit 129 Pleasant Street Brown Building Concord NH 03301 603 271-7342. I understand that the information I authorize a person or entity to receive may be redisclosed and no longer protected by federal privacy regulations. This authorization expires on Persons/organizations authorized to use and/or disclose the information Specific description of information that may be used/disclosed The information will be used/disclosed for the following purposes I understand that this authorization is voluntary and that I may refuse to sign this authorization* I understand that the Department will not condition treatment payment or enrollment in a health plan based on this authorization* I understand that I may revoke this authorization at any time by notifying the Department in writing. This authorization expires on Persons/organizations authorized to use and/or disclose the information Specific description of information that may be used/disclosed The information will be used/disclosed for the following purposes I understand that this authorization is voluntary and that I may refuse to sign this authorization* I understand that the Department will not condition treatment payment or enrollment in a health plan based on this authorization* I understand that I may revoke this authorization at any time by notifying the Department in writing. However the revocation will not be valid if a* The Department has taken action in reliance on this authorization or b.