When Sansum Clinic is requesting permission to use your protected health information for purposes other than treatment, payment or healthcare operations (TPO), or to disclose your PHI to a third party for purposes not outlined above in Section II of this Notice, you may be asked to sign an authorization. Typical examples include (a) disclosing information to an employer for employment decisions, and (b) disclosing information for eligibility for life insurance. Moreover, an authorization will be required to use or disclose psychotherapy notes for treatment by persons other than the originator of the notes.
Click in the links below to download and print our authorization for disclosure forms in English or Spanish:
Authorization for Use/Disclosure of Protected Health Information
Autorización Para Su Uso/Divulgación De Información Confidencial De La Salud
Updated April 2016