Va Benefits Consultants

VA Benefits Consultants

AUTHORIZATION FOR RELEASE AND/OR USE OF CONFIDENTIAL

PROTECTED HEALTH INFORMATION (HIPAA Compliant, 45 C.F.R. 164.508)

HELP US FILL OUT YOUR FUTURE APPLICATION FOR YOU:

Name of Pateint:

Date of Birth:

Social Security Number:

Email address:

City, State, Zip Code:

Street Address:

Cell Phone No.:

Rank while in service:

Branch of Service

Combat zone after 9/2001?:

Region of deployment (if applicable):

Service in Reserves or Guard?:

HELP US PLAN YOUR BEST STRATEGY BETWEEN TEAMS:

Authorization for Use and /or Disclosure: By my signature below I Authorize the following persons, classes of persons, facilities and/or institutions to receive, use and disclose my Protected Health Information (hereinafter PHI) described below for the purpose identified herein:

1-VA Benefits Consultants (hereinafter referred to as “VABC”) and its officers, directors and employees;

2-Any third-party medical or telemedicine firms and service providers engaged by VABC, to perform services on my behalf and the employees and independent contractors of such service providers, including but not limited to nurses and doctors acting for or on behalf of such firms, telemedicine services, and service providers; or

3-In the event I elect to have VABC perform its services through my personal doctor, the following identified Doctor, and the employees of such doctor:

Information to be Used and/or Disclosed: I hereby authorize the use and disclosure of any and all Protected Health Information documents that I personally provide directly to VABC, or which VABC may obtain under a separate authorization for release of Protected Health Information (PHI) that I may sign in the future, to allow VABC to obtain PHI about me from any source other than me. Such PHI includes any and all medical records, including every page thereof, including but not limited to office notes, face sheets, history and physical, consultation notes, inpatient records, outpatient records, emergency room records, all clinical charts, order sheets, progress notes, nurses notes, doctor's orders, treatment plans, admission records, discharge summaries, requests for and reports of consultations, correspondence, test results, statements, questionnaires and histories, photographs, imagining including CT scans, MRis, X-rays, sonograms, videotapes, telephone messages, billing records, pharmacy/prescription records, etc.

Consent to Release and Use of Specially Protected PHI: I understand that my express consent is required to authorize the use or disclosure of certain records, including information related to testing, diagnosis and/or treatment for HIV (the AIDS virus), sexually transmitted diseases, psychiatric, psychological or mental healthdisorders or treatment, or drug and/or alcohol use and treatment. I understand that the information to be used or disclosed pursuant to this Authorization may include such information. By my separate signature affixed here, I confirm that this Authorization is effective as to such records and Protected Health Information and I authorize theuse and disclosure of this type of information.

Purpose of Authorized Use and Disclosure: I have engaged VABC under a separate Service Agreement to consider, evaluate and seek amendment of my current disability rating. The use and disclosure authorized herein is for the purpose of permitting VABC access to all PHI necessary and or helpful to accomplish the task for which I have engaged VABC. I am further authorizing and directing VABC to contact the Veteran’s Administration directly on my behalf with regard to the status of my claim.

Term of Authorization and Right to Revoke: : This authorization shall be valid until the final decision is made by the VA, and payment is made by client/patient. I understand, in addition, that I have the right to revoke this Authorization at any time by a notice delivered to VABC in writing, except to the extent that PHI has already been released in reliance upon this authorization.

Acknowledgment of Possibility of Re-disclosure: I understand that once the information released pursuant to this Authorization is received by the recipient, whether VABC or a third party, it may be re-disclosed and no longer protected under Privacy Laws. I agree to hold VABC, its Directors, Officers and employees harmless from any claim for damages that may occur thereby.

Copies As Effective as Original: Any facsimile, copy or photocopy of this Authorization shall be as effective and enforceable as the original. Authorization Not A Requirement of Services:

I sign this Authorization voluntarily and I understand that signing this Authorization is not required, but I have been advised that my failure to sign this Authorization may detrimentally impact the ability of VABC to obtain an increase in my VA Disability Rating or related benefi

Dated:

SIGNED: