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Notice and authorization perta... FEDERAL DEPOSIT INSURANCE CORPORATION. Notice and Authorization. Pertaining to Consumer Reports. Pursuant to the Fair Credit Reporting Act of 1970 ...

Authorization to disclose pers... Only PrOPerly cOmPleted FOrms will be PrOcessed AuthorizAtion to Disclose PersonAl heAlth informAtion to self Phone: 206-621-4150 Fax: 206-621-4235 1200 - 12th Ave. S., Seattle, WA 98144 Attn: ROI

Mc 315 authorization 2006 form Approved, SCAO Original - Records custodian 1st copy - Requesting party 2nd copy - Patient STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Court address CASE NO. AUTHORIZATION

Ecmc authorization form 898. 3000 ECMC. EDU Health Information Management Department G30 716. 898. 3257/3258 It is understood that any disclosure is bound by 42 CFR Part 2 governing the confidentiality of alcohol and drug abuse patient records and that re disclosure of alcohol and drug abuse information to a party other than the one designated above is forbidden without your additional written authorization. If this authorization involves alcohol and drug abuse patient information it shall expire six 6 months from the date signed unless a different time period event or condition is specified in Section 2 below. AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION PG 1 OF 3 Name Med* Rec* Visit Service Date Date of Birth Insurance Service Time Age Room This form implements the requirements for patient authorization to use and disclose health information protected by the federal health privacy law 45 C. F*R* parts 160 164. Except as otherwise permitted or required by the privacy law a healthcare provider subject to the privacy law may not use or disclose protected health information without an authorization that complies with the requirements of 45 C. F*R* Section 164. 508. Patient/Resident Name Date of Birth Address Phone E Mail address initials Please initial here if you would like your records electronically I hereby authorize the use or disclosure of protected health information as follows 1. The information that may be used or disclosed includes initial applicable line All treatment records. If this is initialed patient must also separately initial the categories below if Behavioral Health records Drug and Alcohol Treatment records and/or HIV related records are to be used or disclosed* Record of treatment during the following time period Behavioral Health/Psychiatric records discharge summary and information below xh Yyzx xh yzx xh y zx If you authorize the release of behavioral health information the disclosing party named above will disclose such information in accordance with Sections 33. 13 and 33. 16 of the Mental Hygiene Law. Drug and Alcohol Treatment records discharge summary and information indicated below ERIE COUNTY MEDICAL CENTER HEALTHCARE NETWORK Rev* 2/13 LGL*100 Erie County Medical Center Corporation 462 Grider Street Buffalo New York 14215 716. NOTE Any information disclosed through this form will be accompanied by Form ALC 440 Prohibition on Redisclosure of Insurance Concerning Alcoholism Patient. HIV Related records discharge summary and information indicated below Due to NYSDOH Chapter 308 of the Laws of 2010 HIV testing Law Mandated August 2010 all patients should be asked to initial this section from redisclosing any HIV related information without your authorization unless permitted to do so under federal or state law. You also have a right to request a list of people who may receive or use your HIV related HIV related information you may contact the New York State Division of Human Rights at 212 480 2493 or 1 800 523 2437 or the New York City Commission on Human Rights at 212 306 7450.

Direct deposit authorization f... Direct Deposit Authorization for Electronic Funds Transfer (EFT) File Maintenance 400 Centennial Office Bldg 658 Cedar Street St Paul, MN 55155 Instructions for completing this form are on the back.

City of chicago hipaa authoriz... City of Chicago Benefits Management Office Authorization Form For the Use and Disclosure of Protected Health Information Name City Employee Name Social Security Number City Employee Social Security

Authorization to defer compens... RSA-1 DEFERRED COMPENSATION PLAN. Remit to Payroll Officer. Please Type or Print Using Black Ink. This form is to be used to begin, cease or change ...

Authorization to take courses... Print Form AUTHORIZATION TO TAKE COURSES ELSEWHERE Approval required before taking courses elsewhere, including Virginia Community Colleges Pamplin College of Business This form serves only as authorization

Treasury authorization form Treasury Collateral Management and Monitoring TCMM Agency Authorization Form Section 1 General Information Create Security Account Delete Security Account Add New User s Delete User Section 2 Agency Information Security Account Name of Agency Name of Bureau Address City Circle One State Zip code Dual Verification will be verified by another agency authorized individual Single Verification Section 3 User Profile s The individuals listed below are collateral contacts under the terms of Title 31 of the Code of Federal Regulations Part 202 or Part 225 and are authorized agency users of TCMM. Each user must have a unique and valid e-mail address. Name Title E-mail Address not shared Area Code Phone By signing below the Agency Official certifies that he/she is duly authorized by the Agency to designate individuals who can manage collateral accounts and serve as user s of TCMM. Name print Signature Title required Phone Fax Date / Please mail or fax the completed form to the TCMM Treasury Support Center Mailing Address TCMM Treasury Support Center Federal Reserve Bank of St* Louis P. O. Box 442 St* Louis MO 63166 866-707-6574 Overnight Address 1421 Dr. Martin Luther King Drive Internal Use Only Date/Time Confirmed with Authorizer Initials Date/Time Verified Authority and Title Date Entered Date Entry Verified Last Updated 09/11 General Notices To access TCMM Users may be issued authentication credentials such as a username and password. We the United States Department of the Treasury and its designated agents may rely upon the authentication credentials alone to provide access to TCMM. We may act upon on any electronic message that we establish to be associated with a known set of authentication credentials as if the message consisted of a written instruction bearing the ink signature of one of the Agency s duly authorized officials. An Agency accepts sole responsibility for and the entire risk arising from the use of authentication credentials by its Users. All Users must agree to terms and conditions governing access to TCMM. These terms and conditions can be found on the Web site s of the application s providing TCMM. These terms and conditions include provisions requiring Users to maintain the confidentiality of their authentication credentials to report the possible theft or compromise of their authentication credentials and to take action whenever they no longer require access or require access to a lesser extent than is currently the case. These terms and conditions are subject to change from time to time. We may have Users click-thru these terms and conditions before first use on a periodic basis or whenever they change to reflect their continued agreement to these terms and conditions. We will not be liable for any loss or damage resulting from a problem beyond our reasonable control* This includes but is not limited to loss or damage resulting from any delay error or omission in the transmission of any electronic information alteration of any electronic information any third party s interception or use of any electronic information a failure of services provided by an Internet service provider and malicious activity received from or introduced by a third party.

F8821 tax authorization form The IRS has created a page on IRS.gov for information about Form 8821 and its instructions at www.irs.gov/ form8821. If you wish to name more than one appointee attach a list to this form. CAF No. Name and address PTIN Fax No. Check if new Address 3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the tax matters listed on this line. Do not use Form 8821 to request copies...

2011 form 8879sp irs e file si... Formulario 8879(SP) Autorizaci n de Firma para Presentar la Declaraci n por medio del IRS e-file OMB No. 1545-0074 Department of the Treasury Internal Revenue Service No env e esta autorizaci n al

Kaiser disclosure form The written revocation will be effective upon receipt except to the extent that the disclosing party or others have acted in reliance upon this authorization. REDISCLOSURE I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. Dispensing summary e.g. tax records. SPECIFY to RECORDS Request for the period from MNVDDW MMODW Records up to the past 36 months are available as a courtesy. Records beyond 37 months are assessed a service fee of 15. 00 per request / per member / patient. Enclose check or money order made to the order of Kaiser Foundation Hospitals KFH. Kaiser Foundation Health Plan Inc. KAISER PERIMIANENTE Southern California Permanente Medical Group Inc AUTHORIZATION FOR USE AND DISCLOSURE OF PHARMACY INFORMATION SOUTHERN CALIFORNIA I understand that Kaiser Permanente will not condition treatment payment enrollment or eligibility for benefits on my providing or refusing to provide this authorization. Disclose to I hereby authodze Kaiser Permanente Pharmacy Print Name of Recipient and / or Kaiser Foundation Hospital Pharmacy Address City State Zip Records and information pertaining to Medical Record Number Date of Birth Telephone Number DURATION This authorization shall become effective immediately and shall remain in effect for this single request for records after which the authorization shall expire. A new authorization form will be required for each future request. REVOCATION This authorization is also subject to written revocation by the member / patient at any time. The written revocation will be effective upon receipt except to the extent that the disclosing party or others have acted in reliance upon this authorization* REDISCLOSURE I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. Dispensing summary e*g* tax records. SPECIFY to RECORDS Request for the period from MNVDDW MMODW Records up to the past 36 months are available as a courtesy. Records beyond 37 months are assessed a service fee of 15. 00 per request / per member / patient. Enclose check or money order made to the order of Kaiser Foundation Hospitals KFH. DO NOT SEND CASH. The recipient may use the pharmacy health information authorized on this form for the following purposes A copy of this authorization is as valid as the original* Member / patient has a right to a copy of this authorization* Please send a copy of Power of Attorney Death Certificate or other legal document as it applies to request of records for another member / patient. Date. Make a copy for your records and Mail completed form to Version 6 REV 6-08 HIPAA COMPL ANT Signature If Signed by Other than Member/Patient Indicate Relationship Pharmacy Informatics PO Box 5075 Livermore CA 94551-5075 Faxed copies will not be accepted* FORM NOT TO BE USED FOR RESEARCH NDIVIDUAL ENROLLMENT OR ELIGIBILITY.

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