2018 Camp Freedom Application

Please type your full name.
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Please specify your position in the company
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Invalid email address.
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Primary Care

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Diabetes Physician

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Camp Freedom Parent Waiver

Please fill in ALL information, initial blanks and sign – one per camper.
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Camp Freedom HIPAA Form

HIPAA Form – South Texas Juvenile Diabetes Association AKA Camp Freedom
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Please type your full name.
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The following information may be used and disclosed in the case of medical necessity (Check the appropriate box(es)):
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This information will be used in case of an emergency and will only be released to nurses, doctors, emergency medical technicians or other personnel needing to care for this person in an emergency. I understand that I may revoke this authorization in writing at any time, except that such revocation will not affect actions already taken in reliance on this authorization and, if applicable may not be effective as to an insurer’s right to contest a claim. I understand that, in order to revoke this authorization, I must send a written notice stating my intent to revoke this authorization to:

South Texas Juvenile Diabetes Association
AKA Camp Freedom
PO Box 720727, McAllen, TX 78504

I understand that the information to be used and disclosed pursuant to this authorization form may include but is not limited to sensitive information such as information to (1) human immunodeficiency Virus (“HIV”) infection or acquired immunodeficiency syndrome (“AIDS”), (2) treatment for or history of drug or alcohol abuse, or (3) mental or behavioral health or psychiatric care. I understand that to the extent any recipient of this information, as identified in Paragraph 3 above, is not a ‘covered entity’ under federal privacy law, the information may no longer be protected by federal privacy law once it is disclosed to that recipient and, therefore, may be subject to re-disclosure by the recipient.
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Please type your full name.
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If authorization is signed by a legal representative of the individual
Printed name of legal representative
Please type your full name.
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Representative’s authority to act as such
Please type your full name.
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