TIEU BANG MASSACHUSETTS
CÔ QUAN CHUYEN TRACH CAC VAN ÑE VE BENH TAM THAN (DMH) Giay öng thuan pho bien thong tin caù nhan
Cho pheùp hai chieu

Ten vaø ho:                                                       Ten khaùc thöôøng duøng: Ñòa chæ:                                                           Ñien thoai:
So an sinh xa hoi:                                             Thaùng, ngaøy, nam sinh:
Toi cho pheùp Cô Quan Chuyen Traùch caùc Van Ñe ve Benh Tam Than (DMH) nhan vaø pho bien thong tin töø hoac cho ngöôøi naøo, hay cô quan ñöôc neu döôùi ñay, qua the thöùc noùi mieng, hoac ghi viet ra tren giay nhö ñöôc neu trong Giay Öng Thuan naøy.

Ten vaø ho:                                             Löu y:ù                              Ñien thoai:

Ñòa chæ:                                                 Thaønh pho:                        Tieu bang:                So Zip:

Nhan vien ñe lien lac tai DMH:
Ten vaø ho:                                                                                     Ñien thoai:

Ñòa chæ:
___________________________________________________________________________________________________________ Ngöôøi ñien mau naøy can ñien ñay ñuû caùc thong tin cap nhat ñöôc yeu cau theo mau. Xin löu yù, mau yeu cau pho bien caùc ghi cheùp trong ho sô tam lyù trò lieu khong the laøm chung cuøng vôùi nhöng yeu cau khaùc. Xin neu ra nhöng loai thong tin can ñöôc pho bien, ví du nhö toaøn bo ho sô trò lieu, caùc thong tin ve nhap vien, ve xuat vien, ve chuyen vien, ve nhan ñònh, ñaùnh giaù vaø xeùt nghiem, khaùm trò vôùi ten chuyen vien phu traùch, ke hoach trò lieu, ke hoach trò lieu caù nhan (ISP) vaø hau ke hoach trò lieu caù nhan (PSTP), caùc khaùm trò than the vaø baùo caùo phoøng xeùt nghiem, caùc ghi cheùp theo chöông trình trò lieu:
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Muc ñích öng thuan:
Caù nhan hoac ñai dien cho caù nhan lien quan ñen öng thuan naøy (khong can ghi muc ñích cu the)
hoac
Phoi hôp viec cham soùc                                         Giaûi quyet ve hoùa ñôn thanh toaùn
Giôùi thieu                                                              Ñang kyù baûo hiem, vaø nhöng quyen lôi taøi chaùnh khaùc
Muc ñích khaùc (xin neu cu the)

Baûn in lai mau öng thuan naøy ñöôc xem laø coù giaù trò nhö mau chaùnh.
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Giay öng thuan pho bien thong tin caù nhan -Cho pheùp hai chieu                                                   Trang 1/2
HIPAA-F4 (4/22/03)
2-Way Consent – Vietnamese

TIEU BANG MASSACHUSETTS
CÔ QUAN CHUYEN TRACH CAC VAN ÑE VE BENH TAM THAN (DMH) Giay öng thuan pho bien thong tin caù nhan
Cho pheùp hai chieu (tiep theo)

Ten vaø ho caù nhan/Bo phan /Cô quan ngoaøi DMH ñöôc pheùp nhan hoac pho bien thong tin: ___________________________
___________________________________________________________________________________________________________ Toi hieu rang toi coù quyen ruùt lai sö öng thuan naøy vaøo bat cöù luùc naøo. Neu muon ruùt lai sö öng thuan, toi phaûi yeu cau tren giay viet vaø nap cho DMH tai ñòa chæ neu ôû Trang 1. Toi cung hieu rang viec quyet ñònh ruùt lai viec öng thuan khong aùp dung cho nhöng thong tin ña ñöôc pho bien tröôùc ñoù theo giay öng thuan naøy. Toi cung hieu rang viec ruùt lai öng thuan khong aùp dung vôùi hang Baûo Hiem cho toi khi luat phaùp cho quyen hang naøy tranh chap nhöng yeu cau theo hôp ñong baûo hiem. Giay öng thuan naøy maûng hieu löc (Ghi cu the thaùng, ngaøy, nam, hoac mot sinh hoat cu the) _____________________ Hoac, neu nhö khong gì ñöôc neu ra, hieu löc öng thuan se cham döùt khi toi khong coøn nhan dòch vu töø DMH. Toi hieu rang mot khi thong tin ña ñöôc pho bien ra ngoaøi DMH, ben nhan thong tin coù the pho bien them ra, vaø thong tin khong ñöôc baûo ve bôûi luat phaùp hay qui ñònh lien bang hoac tieu bang ve quyen rieng tö caù nhan. Toi hieu rang cho pheùp söû dung hoac pho bien thong tin neu tren laø hoaøn toaøn tren cô sôû tö nguyen. Toi khong bò boù buoc phaûi kyù mau naøy ñe nhan ñöôc ñieu trò hoac dòch vu töø DMH vaø/hoac töø nhöng caù nhan, bo phan hoac cô quan khaùc ñöôc neu ten. Ngöôc lai, viec thieu khaû nang chia xeû hoac nhan thong tin coù the  han che dòch vu cham soùc thích nghi vaø can thiet maø nhöng caù nhan, bo phan hoac cô quan ñöôc neu tren cung cap.

_____________________________________________                                                         _______________________ Ñöông sö hoac ngöôøi ñai dien kyù ten                                                                                Thaùng, ngaøy, nam

_____________________________________________ Ghi roû ten ngöôøi kyù

NHÖNG THONG TIN SAU ÑAY CAN THIET NEU NGÖÔI ÑAI DIEN KY TEN:

Loai quyen ñai dien (ví du: Do Toøa Aùn chæ ñònh, quyen baûo ho treû em)______________________________________________

Nhöng thong tin cu the ñöôc pheùp pho bien (xin ghi tat ten ho canh caùc muc yeu cau coù lien quan)
_________         Ô chöøng möc maø ho sô y te cuûa toi chöùa ñöng nhöng thong tin ve ñieu trò nghien röôu hoac ma tuùy ñöôc
Qui Ñònh Lien Bang 42 CFR, phan 2.1 baûo ve vaø cho pheùp mot caùch cu the viec pho bien nhöng thong tin naøy.

 _________         Ô chöøng möc maø ho sô y te cuûa toi chöùa ñöng nhöng thong tin ve xeùt nghiem khaùng to vaø khaùng the HIV ñöôc ñao luat MGL chöông 111§70F baûo ve, ve chan ñoaùn vaø ñieu trò benh HIV/AIDS, toi cu the öng thuan cho pho bien nhöng thong tin naøy.

_____________________________________________                                                         _______________________ Ñöông sö hoac ngöôøi ñai dien kyù ten                                                                                Thaùng, ngaøy, nam
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CHÆ DAN:
1.   Mau naøy can ñöôc ñien ñay ñuû ñe coù hieu löc
2.   Phan phoi caùc baûn: baûn chaùnh cho vaøo ho sô DMH coù lien quan; baûn sao cho caù nhan hoac ngöôøi ñai dien;
baûn sao cho caù nhan/bo phan/cô quan yeu cau viec öng thuan.
___________________________________________________________________________________________________________ Giay öng thuan pho bien thong tin caù nhan - Cho pheùp hai chieu                                                  Trang 2/2
HIPAA-F4 (4/22/03)
2-Way Consent - Vietnamese