Do you need assistance purchasing an accessible vehicle or modifying a vehicle?
Do you need help in order to attend a Duchenne conference or educational event?
Do you need urgent assistance?
Do you need assistance obtaining equipment that is not covered by your insurance? If you've received an insurance denial, do not check this box. Please click the category below titled "Insurance denials/Questions/Information".
Do you need assistance figuring out how to get an item covered by your insurance? Have you received an insurance denial for any prescribed item such as equipment, prescribed medication, therapies or other services? Do you have general questions about your healthcare coverage or obtaining healthcare coverage?
Do you need help locating/enrolling in a Medicaid waiver in your state? Is the applicant already enrolled in a Medicaid waiver program and needs help understanding what services you may be eligible to receive? Do you need guidance navigating government benefits such as Medicaid, SSI, SSDI, Medicare, vocational/occupational services, housing programs, etc?
Do you need help with locating resources or financial assistance to make your home accessible?
Do you need assistance traveling to a Duchenne clinic/doctor?
Do you need help finding other community resources or support not mentioned here? Do you need help obtaining prescribed medication, equipment or other items because you have no health care insurance? Please mark this option only if your need is outside of the categories outlined above, and we will do our best to help you.
Please make a selection.
Please make a selection.
Please enter patient first name.
Please enter patient last name.
Please enter patient birthday.
Please enter number and street.
Please enter city.
Please enter zip or postcode.
Please select country.
 
Please enter first name.
Please enter last name.
Please enter email address.
Please make a selection.
Please make a selection.
No file(s) selected
 
No file(s) selected
 
 
No file(s) selected
 
Please select language.
 

I, , an individual, intend for the Duchenne Family Assistance Program, a team of two charitable organizations, ("DFAP") to be treated as I would be with respect to my rights regarding the use and disclosure of my individually identifiable health information or other medical records. It is my intention to waive the requirement that DFAP be given only the "minimum necessary" information, and it is my express intent that DFAP shall have full and unfettered access to any and all information that I provide personally or via any other personal representative. This release authority applies to any information governed by the Health Insurance Portability and Accountability Act of 1996 (aka HIPAA), 42 USC 1320d and 45 CFR 160-164.

This Authorization to Disclose Health Information is intended to be a "valid authorization", as that term is used in the Health Insurance Portability and Accountability Act of 1996, as amended, and in regulations promulgated thereunder, including, without limitation, 45 C.F.R. §164.508, or any successor regulatory provision.

I hereby authorize:

• any physician, healthcare professional, dentist, health plan, hospital, clinic, laboratory, pharmacy or other covered health care provider, any insurance company, the Medical Information Bureau, Inc., or other health care clearinghouse that has provided treatment or services to me, or that has paid for, or is seeking payment from me for such services except as may be specifically limited below:

• to give, disclose and release to DFAP, without reservation,

• all of my individually identifiable health information and medical records regarding any past, present or potential future medical or mental health condition, to include, but not be limited by, all information related to the diagnosis and treatment of HIV/AIDS, sexually transmitted diseases, mental illness and the mental health records protected by the Lanterman-Petris-Short Act, and drug or alcohol abuse, except as specifically limited below:

The authority given DFAP shall supersede any prior agreement that I may have made with my health care providers to restrict access to or disclosure of my individually identifiable health information.

This authorization shall terminate on the first to occur of: (1) Two (2) years after my death; or (2) Upon my written revocation actually received by the DFAP. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the covered entity. This revocation shall be effective upon the actual receipt of the notice by the covered entity except to the extent that DFAP has taken action in reliance on this Authorization.

By signing this Authorization, I acknowledge that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the person or persons named in this authorization and the information once disclosed will no longer be protected by the rules created in HIPAA.

I understand that although federal law does not protect health information which is disclosed to someone other than another health care provider, health plan or health care clearinghouse, under California law all recipients of health care information are prohibited from re-disclosing such information except as specifically required or permitted by law.

I understand that I have the right to receive a copy of this authorization.

Agreed this 25th day of October, 2021.

Please make a selection.