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Alcpt Form 78


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CERTIFICATION OF HEALTH By signing this form I certify that I am a qualified health professional and that I have the right for my child to have all necessary and appropriate medical care. Signing this form means I do not have a medical condition that would prevent me from signing. I also certify that all statements regarding facts included in this form are true. I certify that all statements regarding opinions expressed in this form are true. I understand that my parental permission for this form to be signed is required. Signing this form means I do not have a medical condition that would prevent me from signing. I also certify that all statements regarding opinions expressed in this form are true. I understand that my parental permission for this form to be signed is required. Signing this form means I do not have a medical condition that would prevent me from signing. I also certify that all statements regarding opinions expressed in this form are true. Alcpt Form 78 SYSTEM OF HEALTH CARE Alcpt Form 78 POLICY STATEMENT In accordance with the law, as outlined in the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations as well as other standards, including but not limited to, applicable state and federal laws and rules, this statement governs the U.S. Health Insurance Portability and Accountability Act of 1996 provides at Title I, Section 1555 of the Public Health Service Act, "Standards for certain health care electronic transactions." This statement provides the health care community with the information required to ensure compliance with the U.S. Health Insurance Portability and Accountability Act of 1996 (HIPAA) and contains provisions that cover the electronic transmission of personal health information of patients and covered individuals. I have read and understand the HIPAA privacy rule and agree to comply with its terms, including use of the Internet and other electronic media. I will not transmit personally identifying information about another individual through this electronic transmission. I understand that any responses I provide on this electronic record are solely for the purpose of providing health care or for administrative purposes. By signing this form, I certify that the transmission of personally identifiable information to the U.S. Department of Health and Human Services is exempt from the safeguards required by the U.S. Health Insurance Portability and Accountability Act of 1996. SIGNATURE I authorize the U.S. Department of Health and Human Services to use the information provided in this application, including any accompanying questions and answers, in any manner or media deemed




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