Authorization for Use or Disclosure of Health Information
PRIVACY POLICY: Friends of Friends will maintain the privacy of your health information as required by law. Friends of Friends agrees to not use or further disclose any personal health information other than as specifically permitted or required by law. We will use appropriate, reasonable safeguards to prevent use or disclosure of this information.
1. My Authorization
When I request assistance with payment for medically related bills, Friends of Friends may use, disclose or discuss my health information with the entity that issued the bill, e.g. a pharmacy, doctor’s office or other medical institution.
2. My Rights
I may revoke this authorization in writing. I understand that an email message or a mailed letter will terminate this agreement. Please email your letter of revocation to info@fofmedicalsupportfund.org, or mail to Friends of Friends, P.O. Box 812, Langley, WA 98260.
3. Signature
The following constitutes the digital signature of the patient or their legally authorized representative.