Jewish Camps USA

HIPAA Release Form

(Health Insurance Portability and Accountability Act) HIPAA is a US law designed to provide privacy standards to protect patients’ medical records and other health information.

This means that if you require medical assistance while in the US, and Jewish Camps USA ask your healthcare provider for medical information in order to assist you, by law, the request for your information would not be granted, under any circumstances.

This document provides the ability for healthcare providers to share information with Jewish Camps USA so that we can assist you.

By completing this form, you give consent to Jewish Camps USA or its designated representative, your parents or guardian, and your physicians and/or other medical providers to discuss your medical and/or insurance issues. You also consent to Jewish Camps USA utilizing any such material as necessary in treating any medical condition that may arise. You also give consent that Jewish Camps USA may notify your emergency contact listed in your application of any situation that we deem to be an emergency.

This authorization is valid for two years from the date signed.

Under no circumstances can Jewish Camps USA release medical information from your physician or provider of service to you or anyone. Your medical information has been disclosed to us by your physician or provider of service, and we are prohibited by federal law from further disclosure. Please contact your physician or provider of service for your medical information.