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Summary: AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
By law, the health insurance plans of Williams College may use or disclose a person's
protected health information without the person's authorization in order to carry out the person's
treatment, to coordinate payment for treatment, or to run their health care operations. They may
also use or disclose this information without the person's authorization to the extent allowed by
law, such as reports to public health agencies.
Uses and disclosures of your protected health information for other purposes require your
written authorization, which you can provide by completing and signing this form.
Part One:
Your name: ____________________ Your Social Security Number: ________________
(Print Name)
Part Two: I authorize ____________________________________________________
(fill in Williams College office or department)
of Williams College to disclose my health care information to:
Name, office or entity: ________________________________________________
Address: ____________________________________________________________
City, State: ____________________________________ Zip Code: _______________
(for example, for assisting in resolving a claims dispute with the insurance carrier)
Part Three: This authorization applies to (check one of the following):
_______ All of my health care information.
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