Frames Data

Data Privacy & Disclosure

Authorization Form

HIPAA, the Health Insurance Portability and Accountability Act, requires that all medical providers and their affiliates put in placecontrols to ensure that personal medical information is secured. The purpose of this form is to grant Compulink authorization of disclosure of Protected Health Information. (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)
- The medical information may be used by the organization I authorize to receive this information for assisting me with data extraction from Compulink Cloud Services.
- The release of information covers all past, present, and future periods, unless otherwise stated by me.
- This authorization shall beinforce and effect until I inform Compulink of my intention to sever my partnership with the organization receiving this information.
- I have the right to withdraw permission for the release of this information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
I hereby authorize Compulink Business Systems, Inc. and its affiliates, employees and agents to disclose Protected Health Information to:
Vendor Interfaces support by Compulink Cloud (check all that apply)*

Solution ReachDemand Force4Patient CareWest/TelevoxWeaveGPN/EdgeFigMD/Iris RegistryClear Wave/ByteSizedOther
Business Name:*
Compulink Account*
Business Address:*
City:*
State:*
Zip*
Signed By:*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
Signature*

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Providing our clients with fully HIPAA compliant solutions is Compulink’s top priority. In addition to HIPAA compliance within our own system, we ensure that any proprietary application accessing clients’ data, does so in such a way that complies with HIPAA health-data security standards, as well as ONC and CCHIT requirements.

There is no setup fee for this service, A $10 monthly API support fee for each vendor interface will be added to your Partnership Care Agreement. It may be discontinued if you elect to no longer use these third-party services by notifying Compulink in writing 30 days in advance.
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