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Form CVH-184 Authorization for Use and Disclosure of Protected Health Information - Connecticut (English / Spanish)
What Is Form CVH-184?
This is a legal form that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form CVH-184?
A: Form CVH-184 is a document used in Connecticut to authorize the use and disclosure of protected health information.
Q: Who should use Form CVH-184?
A: Anyone in Connecticut who wants to authorize the use and disclosure of their protected health information can use Form CVH-184.
Q: Is Form CVH-184 available in both English and Spanish?
A: Yes, Form CVH-184 is available in both English and Spanish.
Q: What is the purpose of Form CVH-184?
A: The purpose of Form CVH-184 is to allow individuals to give their consent for the use and disclosure of their protected health information in Connecticut.
Q: Is Form CVH-184 specific to Connecticut?
A: Yes, Form CVH-184 is specific to Connecticut and its laws regarding the use and disclosure of protected health information.
Q: Is there a fee to use Form CVH-184?
A: No, there is no fee to use Form CVH-184.
Q: Can I revoke my authorization on Form CVH-184?
A: Yes, you can revoke your authorization on Form CVH-184 at any time by notifying the healthcare provider or facility in writing.
Q: Is Form CVH-184 legally binding?
A: Yes, Form CVH-184 is a legally binding document once it is properly completed and signed.
Q: What information is required on Form CVH-184?
A: Form CVH-184 requires your personal information, the purpose of the authorization, a description of the information to be used or disclosed, and the names of the individuals or entities authorized to receive the information.
Q: Can I use Form CVH-184 for someone else?
A: Yes, you can use Form CVH-184 to authorize the use and disclosure of protected health information for someone else if you have the legal authority to do so.
Q: How long is Form CVH-184 valid?
A: Form CVH-184 is valid for one year from the date of signature, unless a different time period is specified.
Form Details:
- Released on August 9, 2010;
- The latest edition provided by the Connecticut Department of Mental Health & Addiction Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form CVH-184 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Mental Health & Addiction Services.
Download Form CVH-184 Authorization for Use and Disclosure of Protected Health Information - Connecticut (English / Spanish)
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