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HIPAA Disclosure
OVERVIEW:
This form authorizes the Health & Insurance Services Office at Daemen University to
communicate with and/or disclose information regarding the undersigned’s health and
medical information to the parties listed below.
DURATION:
This authorization shall become effective immediately and shall remain in effect as long
as the person completing this form remains a student at Daemen University.
STUDENT’S RIGHTS:
I may revoke or amend this authorization at any time. My revocation must be submitted
in writing to the Health & Insurance Services Office. I have a right to receive a copy of
this authorization.
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* Indicates required question
Email
*
Your email
First name
*
Your answer
Last name
*
Your answer
Date of birth
MM
/
DD
/
YYYY
Phone number
*
Your answer
By checking the box below, I hereby authorize the Health & Insurance Services Office to communicate about any health issues and/or new or pre-existing medical conditions and health insurance related information with the party (parties) designated
*
I authorize the sharing of medical information with the party (parties) designated
Required
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