Annual Data Authorization Form

Annual Data Authorization Form

This form is designed to authorize the use and disclosure of healthcare data.

Program Information

Program

    • Medicare

    • Medicaid

    • Children's Health Insurance Program (CHIP)

    Enrollment ID No.

      Contract ID No.

        Enrollment Start Date

          Service Start Date

            Assigned Staff

              Authorization for Service

              I have been informed about the specified program and wish to receive services. I understand that my personal health information will be collected, maintained, and securely stored in a database to track services and ensure quality care is provided. This data may be used for evaluation, billing, and compliance purposes. I hereby authorize myself and/or my dependent(s) to receive these services as part of the selected healthcare program.



              Name:

              Date:

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