{"id":777,"date":"2025-09-04T18:59:34","date_gmt":"2025-09-04T23:59:34","guid":{"rendered":"https:\/\/medicount.com\/?page_id=777"},"modified":"2025-09-30T15:07:28","modified_gmt":"2025-09-30T20:07:28","slug":"hipaa-authorization-form","status":"publish","type":"page","link":"https:\/\/medicount.com\/es\/hipaa-authorization-form\/","title":{"rendered":"Formulario de Autorizaci\u00f3n HIP\u0410\u0410"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><div class=\"vc_row wpb_row vc_row-fluid\"><div class=\"wpb_column vc_column_container vc_col-sm-12\"><div class=\"vc_column-inner\"><div class=\"wpb_wrapper\"><\/div><\/div><\/div><\/div><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_3' >\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_3'  action='\/es\/wp-json\/wp\/v2\/pages\/777' data-formid='3' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/777\"> \r\n <input type='hidden' class='gforms-pum' value='{\"closepopup\":false,\"closedelay\":0,\"openpopup\":false,\"openpopup_id\":0}' \/>\n                        <div class='gform-body gform_body'><ul id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><li id=\"field_3_2\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Paciente\/Otros<\/h2><\/li><li id=\"field_3_77\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_77'>N\u00famero de cuenta<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_3_77' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_78\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_78'>Fecha de Servicio:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_3_78' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_1\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_1'>Nombre:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_3_1' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_4\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_4'>Tel\u00e9fono:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_3_4' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_59\" class=\"gfield gfield--type-email gfield--input-type-email gf_middle_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_59'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_59' id='input_3_59' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_3_57\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_57'>Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_3_57' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_58\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_58'>Ciudad\/Estado\/C\u00f3digo postal:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_3_58' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_56\" class=\"gfield gfield--type-text gfield--input-type-text gf_middle_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_56'>Fax:<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_3_56' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_5\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Prop\u00f3sito de Divulgaci\u00f3n<\/h2><\/li><li id=\"field_3_63\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Prop\u00f3sito de Divulgaci\u00f3n<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_63'><li class='gchoice gchoice_3_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='At the request of the patient'  id='choice_3_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_1' id='label_3_63_1' class='gform-field-label gform-field-label--type-inline'>A solicitud del paciente<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_63_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.2' type='checkbox'  value='Other'  id='choice_3_63_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_63_2' id='label_3_63_2' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_64\" class=\"gfield gfield--type-text gfield--input-type-text gf_one_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_64'>Si Otro (por favor especifique)<\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_3_64' type='text' value='' class='medium'      aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_right_third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Tipo de Informaci\u00f3n a Divulgar:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_66'><li class='gchoice gchoice_3_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Billing and Ambulance Transport Records'  id='choice_3_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_66_1' id='label_3_66_1' class='gform-field-label gform-field-label--type-inline'>Registros de facturaci\u00f3n y transporte en ambulancia<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_3_68\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><ol>\n<li>  Entiendo que la informaci\u00f3n utilizada o divulgada de conformidad con esta Autorizaci\u00f3n puede estar sujeta a una nueva divulgaci\u00f3n por parte del destinatario y puede que ya no est\u00e9 protegida por las regulaciones federales de privacidad, incluidas las Normas de Privacidad de HIPAA.<\/li>\n<li>Puedo revocar esta Autorizaci\u00f3n en cualquier momento notificando por escrito al Proveedor de\nAtenci\u00f3nM\u00e9dica. Entiendo que dicha revocaci\u00f3n no se aplicar\u00e1 a ninguna acci\u00f3n ya realizada en base a\nesta Autorizaci\u00f3n antes de la fecha en que se reciba la revocaci\u00f3n.<\/li>\n<li>  Entiendo que el tratamiento, el pago, la inscripci\u00f3n o la elegibilidad para beneficios por parte de\ncualquier entidad no puede estar condicionado a que yo proporcione esta Autorizaci\u00f3n.<\/li>\n<li>This Authorization will expire seven (7) years from the date of signature, or upon the final resolution and closure of all claims, lawsuits, or settlements related to my care on the identified date(s) of service, whichever occurs later.<\/li>\n<li>  Reconocimiento sobre la comunicaci\u00f3n por correo electr\u00f3nico: Si he proporcionado una direcci\u00f3n de\ncorreo electr\u00f3nico arriba, reconozco que, a menos que el correo est\u00e9 encriptado o asegurado de otra\nmanera, existe el riesgo de que la informaci\u00f3n de salud protegida (PHI) pueda ser accedida por terceros\nno autorizados durante la transmisi\u00f3n.<\/li><\/ol><\/li><li id=\"field_3_69\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">RECONOCIMIENTO DEL PACIENTE<\/h2><div class='gsection_description' id='gfield_description_3_69'>Al firmar a continuaci\u00f3n, reconozco que he le\u00eddo y acepto los t\u00e9rminos de esta Autorizaci\u00f3n, incluidas las\ncondiciones de expiraci\u00f3n.<\/div><\/li><li id=\"field_3_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full signature-field gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_80'>Firma del paciente o del representante del paciente:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_3_80' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_73\" class=\"gfield gfield--type-text gfield--input-type-text gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_73'>Nombre impreso del representante del paciente (si corresponde):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_3_73' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_3_74\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_left_half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Relaci\u00f3n con el paciente:<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_3_74'><li class='gchoice gchoice_3_74_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.1' type='checkbox'  value='Parent'  id='choice_3_74_1'   aria-describedby=\"gfield_description_3_74\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_3_74_1' id='label_3_74_1' class='gform-field-label gform-field-label--type-inline'>Padre\/Madre<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_74_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.2' type='checkbox'  value='Legal Guardian'  id='choice_3_74_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_74_2' id='label_3_74_2' class='gform-field-label gform-field-label--type-inline'>Tutor legal<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_3_74_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_74.3' type='checkbox'  value='Other'  id='choice_3_74_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_74_3' id='label_3_74_3' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_3_74'> *La documentaci\u00f3n legal de la autoridad del representante debe acompa\u00f1ar esta Autorizaci\u00f3n.<\/div><\/li><li id=\"field_3_71\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_3_71'>Fecha<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_71' id='input_3_71' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/aaaa' aria-describedby=\"input_3_71_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_3_71_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_3_71' class='gform_hidden' value='https:\/\/medicount.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_3' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_3' id='gform_theme_3' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_3' id='gform_style_settings_3' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJbXSIsIjMyODJjM2VkZDBlZGFhZjUwMDMxZWU2MmYxMTA2OGQyIl0=' \/>\n            <input type='hidden' 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