Professional legal forms

Letter of consent application... Work Pass Division 18 Havelock Road Singapore 059764 www.mom.gov.sg Letter of Consent Application Form This form may take you 10 minutes to fill in. You will need the following information to fill

Physical therapy consent form ATI Physical Therapy Consent Form Consent to treatment I hereby grant consent for treatment or services to be provided by ATI Physical Therapy athletic training staff and team physicians. Disclosure of Protected Health Information I understand that my personal health information is protected by federal regulations under either the Health Information Portability and Accountability Act HIPAA or the Family Educational Rights and Privacy Act of 1974 FERPA and may not be disclosed without either my authorization or consent. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation* training staff for purposes of providing athletic training and medical services reporting and providing information and communications with coaches administrators physical therapists doctors and other allied health professionals. This authorization will allow athletic trainers to disclose medical information to coaches school officials and athletic directors on a need to know basis. This will ensure the safety of the athlete while participating in sports as well as establish a communication channel for coaches to stay abreast of an athlete s playing status and medical condition* Medical information shared between medical providers coaches and school administrators is confidential information and will not be shared to those outside these positions. I herby consent to and authorize ATI Physical Therapy s athletic trainers physical therapists and other health care personnel to disclose protected health information and any related information regarding an injury or illness during my training for purposes stated* I also consent to and authorize the release of protected health information to my parents or guardians. I also understand that the local regional and national media are not covered by HIPAA or FERPA and that these legal requirements will not apply. Expiration or Revocation athletics. I understand I have the right to revoke authorization at any time by sending written notification to ATI Physical Therapy s Director of Sports Medicine. Both the Athlete and Parent/Guardian Must Sign if under 18 years of age. Name of Athlete Signature of AthleteDate Name of Parent/Guardian Signature of Parent/GuardianDate. Disclosure of Protected Health Information I understand that my personal health information is protected by federal regulations under either the Health Information Portability and Accountability Act HIPAA or the Family Educational Rights and Privacy Act of 1974 FERPA and may not be disclosed without either my authorization or consent. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation* training staff for purposes of providing athletic training and medical services reporting and providing information and communications with coaches administrators physical therapists doctors and other allied health professionals. I also understand that I am not required to sign this authorization/consent in order to be eligible for participation* training staff for purposes of providing athletic training and medical services reporting and providing information and communications with coaches administrators physical therapists doctors and other allied health professionals. This authorization will allow athletic trainers to disclose medical information to coaches school officials and athletic directors on a need to know basis.

Consent to obtain information... CONSENT TO OBTAIN INFORMATION University of Iowa Hospitals and Clinics FORM 1991 Hosp. #: Please PRINT (except signatures) and provide complete answers (information) in each section. Patient s Legal

Affidavit support consent form AFFIDAVIT OF SUPPORT AND CONSENT and SPECIAL POWER OF ATTORNEY I of legal age Filipino single/married to 1. I am/We are the father and/or mother of the minor s Name Age Said minor/s is/are applying for Philippine passport/s at the Department of Foreign Affairs I am/We are appointing presently residing at applying for a passport at the I/We authorize presently residing at of Social Welfare and Development for my/our child/children who will be travelling to his/her/their travel to I am/We are willing and able to support my/our child/children during the said travel On the said travel my/our child/children will be staying at Though the father/mother of said child/children is not here present I am giving consent to the above acts in as much as check one that applies said father/mother has earlier voluntarily and freely given his/her consent with no condition imposed whatsoever and requested that said consent be relayed by me. I have exclusive legal custody of minor single parent see attached divorce papers/death certificate of spouse I/We assume responsibility for the issuance of the passport and for allowing the trip of the said minor/s and further assume all obligations consequent thereto and I/We am/are executing this Affidavit to attest to the truth of the above statements and for whatever legal purpose this may serve. I have exclusive legal custody of minor single parent see attached divorce papers/death certificate of spouse I/We assume responsibility for the issuance of the passport and for allowing the trip of the said minor/s and further assume all obligations consequent thereto and I/We am/are executing this Affidavit to attest to the truth of the above statements and for whatever legal purpose this may serve.

Short form application for wri... 1998 National Association of Insurance Commissioners. SHORT .... Attach the following documents to this Application for written consent. Applications ... Application and I expressly consent and authorize

Printable utah state functiona... FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED BY APPLICANT - Please use BLACK ink Fax Number 801 957-8698 www. I also understand that I may revoke this authorization at any time by sending written notification to the Utah Driver License Division at the above address. I understand that if I fail to sign this authorization my driving privilege may be affected. I understand that this informat...

This is the only medical repor... Department of the Secretary of State Bureau of Motor Vehicles WORK-RESTRICTED DRIVER'S LICENSE PETITION Applies to Class C, Non-Commercial Driving Privileges Only ***You must submit your license and

Medical report disability supp... Medical Report Disability Support Pension Customer s details Full name Address / Date of birth Phone number Your Centrelink Reference Number This information will help the Australian Government Department of Human Services in determining income support eligibility if the customer may benefit from a program of assistance or training Instructions for the customer Information for the doctor 1 Complete your details above. 2 Contact your doctor or medical specialist and make an appointment to have the Medical Report completed* Make sure the doctor and their receptionist know that you will need this report completed as a long consultation may be required* If your doctor does not bulk bill your consultation fee may be more than usual because of the extra time taken to complete the report. Important information A doctor or medical specialist is a person registered and licensed under a state or territory law that provides for the registration or licensing of medical practitioners. It includes only those with recognised medical qualifications such as general practitioners and medical specialists and excludes those with non-medical qualifications e*g* psychologists or physiotherapists. Note If a person has an intellectual impairment and this is their only condition the Medical Report can be completed by the person s treating psychologist. 3 Attend the appointment with your doctor or medical specialist. Completing this report You can complete and lodge Medical Reports electronically through Health Professional Online Services HPOS. For more information go to our website humanservices. gov*au/healthprofessionals and logon to HPOS* In this report you will be asked to provide information about your patient s medical condition s. Please complete all the required questions in this report. If you require another paper copy of the Medical Report go to our website humanservices. gov*au/forms If you need more information in order to complete the Medical Report call us on 132 150. www. Returning this report You can give this report and any attachments to your patient or you can return it to Department of Human Services Disability Services Reply Paid 7806 CANBERRA BC ACT 2610 Continued 4 When your doctor or specialist has completed this Medical Report it must be returned to us. 5 If you have other relevant information such as specialist medical reports or an assessment of your intellectual function showing your IQ score if relevant to your claim return them to us with this report. CLK0SA012 1311 SA012. 1311 1 of 11 Important This request is a notice given under section 63 of the Social Security Administration Act 1999. Request for clarification of additional information Human Services including staff from the Health Professional Advisory Unit may make contact with you to discuss the information in your report. These contacts will only occur where information requires clarification* Privacy and your personal information Your personal information is protected by law including the Privacy Act 1988 and is collected by the Australian Government administration of payments and services.

Imm 1017 form Fillable Form Citizenship and Immigration Canada Citoyennet et Immigration Canada PROTECTED WHEN COMPLETED - B FOR OFFICIAL USE ONLY CASE PROCESSING CENTRE - VEGREVILLE IMS Serial Number: FOSS Client

Medical report blank page form Items 62 - 71 ... DD FORM 2808, AUG 2000. Page 1 of 3 Pages. CLINICAL EVALUATION (Check each item in appropriate ...

Imm 1017b form pdf OP 15 Medical Procedures Updates to chapter .................................................................................................................... 4 1. 2. 3. 3.1. 4. 4.1. 5. 5.1. 5.2.

Eaedc medical report form 2009 Follow these steps Fill out this Medical Records Release Form before you give the EAEDC Medical Report to your medical and mental health care provider. Call UMASS/Disability Evaluation Services DES at 1-800-888-3420 with questions you may have regarding the completion of this report. EAEDC-Med Rpt Rev. 5/2009 04-012-0509-05 Blank Page Department of Transitional Assistance DTA and Disability Evaluation Services DES Medical Records Release Form Sign this form to let your medical and mental health care provider share information with UMASS/Disability Evaluation Services DES. PATIENT INFORMATION Last Name Date of Birth First Name Social Security Number Address Street City State Zip Code Telephone Number Massachusetts Department of Transitional Assistance EAEDC Medical Report General Instructions to Medical and Mental Health Care Providers Your patient has applied for cash and medical assistance under a DTA program as disabled* To be eligible your patient must file an EAEDC Medical Report so that eligibility can be determined* Regulations for a disability determination require that a diagnosis be supported by specific clinical findings. The medical data provided by you in the report clinical findings diagnosis test results will be used by DTA to determine disability. For these purposes an individual is disabled if he or she has an impairment or combination of impairments that is expected to last 60 days or more and that substantially reduces or eliminates the applicant s or recipient s ability to support himself or herself* If you need a copy of DTA s regulations regarding a disability determination telephone 617 348-5299 and leave a message or refer to DTA s regulations by visiting the Mass. gov website at http //www. mass. gov/Eeohhs2/docs/dta/greg320. pdf The Department will pay for the medical evaluations needed to complete a Medical Report including diagnostic tests through its regular medical billing system MMIS. Please use your regular MassHealth Provider Number when submitting invoices for these services. The EAEDC Medical Report must be signed by a Competent Medical Authority. Please refer to page 7 for details before proceeding further. functioning. It is essential that when you complete the EAEDC Medical Report you supply all relevant information* Complete the EAEDC Medical Report in full with respect to the conditions that are relevant to the patient. Sign and return it to the patient or mail it to the DTA Transitional Assistance Office indicated on page 8. Call UMASS/Disability Evaluation Services DES at 1-800-888-3420 with questions you may have regarding the completion of this report. EAEDC-Med Rpt Rev* 5/2009 04-012-0509-05 Blank Page Department of Transitional Assistance DTA and Disability Evaluation Services DES Medical Records Release Form Sign this form to let your medical and mental health care provider share information with UMASS/Disability Evaluation Services DES. HOW TO FILL OUT THIS FORM Your medical and mental health care provider will only send medical records to UMASS/Disability Evaluation Services if you fill out the form right.

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