• AUTHORIZATION TO RELEASE/OBTAIN CONFIDENTIAL INFORMATION

  • Section A

    Use or Disclosure of Health Information
  • By signing this form, I authorize the disclosure/acquirement of my protected health information maintained by:

    Ku Aloha Ola Mau

    1130 N. Nimitz Hwy C-302

    Honolulu, HI 96817

    (808) 538-0704

    My health information may be disclosed to:

  • Section B

    Scope and Use of Disclosure

  • Section C


  • Section D

    Forms of Information (Initial all forms in which consent applies):
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  • Section E

    Other Important Information
  • This consent may be revoked at any time, upon notice of the person who has signed below, except when action has already been taken. Without revocation, this consent will expire one year from date of signature.

    The types of medical information above cannot be released without my specific consent and knowledge. I hereby release Kū Aloha Ola Mau and its staff from all liability and all claims of any nature pertaining to the disclosure of information of any professional opinions, findings, or recommendations contained in these records.

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  • Redisclosure is prohibited. This information has been disclosed to you from records protected by Federal (42 CFR part 2), Federal Health Insurance Portability and Accountability Act (HIPAA 45 CFR, parts 160 & 164), and State (HRS 325-101) confidentiality rules. The Federal rules and State law prohibit further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2, HIPPA, and HRS 325-101. A general authorization for the release of medical or other information is NOT sufficient for this purpose. Revised: April 2007 Rev: 3/2011 MQ

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