{"id":423,"date":"2024-06-21T11:18:29","date_gmt":"2024-06-21T11:18:29","guid":{"rendered":"https:\/\/demolinks2.com\/baffour-agyeman\/?page_id=423"},"modified":"2024-06-21T11:19:39","modified_gmt":"2024-06-21T11:19:39","slug":"release-of-information-en-espanol","status":"publish","type":"page","link":"https:\/\/demolinks2.com\/baffour-agyeman\/release-of-information-en-espanol\/","title":{"rendered":"Release of Information &#8211; En Espa\u00f1ol"},"content":{"rendered":"<div class=\"wpb-content-wrapper\"><p>[vc_row][vc_column]\t\t<div id=\"wd-667561b02fc9b\" class=\"wd-image wd-wpb wd-rs-667561b02fc9b text-center  refrl-frm-img\">\n\t\t\t\n\t\t\t<img loading=\"lazy\" decoding=\"async\" width=\"1239\" height=\"938\" src=\"https:\/\/demolinks2.com\/baffour-agyeman\/wp-content\/uploads\/2024\/04\/WDD-US-21032024-56483221334-Resilience-Psychiatry-01.png\" class=\"attachment-full size-full\" alt=\"\" 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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\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_8' ><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/baffour-agyeman\/wp-json\/wp\/v2\/pages\/423#gf_8' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_8_14\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Consentimiento de divulgaci\u00f3n de informaci\u00f3n<\/h2><\/div><div id=\"field_8_1\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_1'>Nombre del cliente:<\/label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_8_1' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_3\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Autorizo a [NOMBRE DEL CONSULTORIO o M\u00c9DICO] a:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_3'><div class='gchoice gchoice_8_3_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.1' type='checkbox'  value='Enviar'  id='choice_8_3_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_3_1' id='label_8_3_1' class='gform-field-label gform-field-label--type-inline'>Enviar<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_3_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_3.2' type='checkbox'  value='Recibir'  id='choice_8_3_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_3_2' id='label_8_3_2' class='gform-field-label gform-field-label--type-inline'>Recibir<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_4\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >La siguiente informaci\u00f3n:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_8_4'><div class='gchoice gchoice_8_4_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.1' type='checkbox'  value='Historial m\u00e9dico y evaluaciones cl\u00ednicas'  id='choice_8_4_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_4_1' id='label_8_4_1' class='gform-field-label gform-field-label--type-inline'>Historial m\u00e9dico y evaluaciones cl\u00ednicas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_4_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.2' type='checkbox'  value='Evaluaciones de salud mental'  id='choice_8_4_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_4_2' id='label_8_4_2' class='gform-field-label gform-field-label--type-inline'>Evaluaciones de salud mental<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_4_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.3' type='checkbox'  value='Desarrollo y \/ o historia social'  id='choice_8_4_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_4_3' id='label_8_4_3' class='gform-field-label gform-field-label--type-inline'>Desarrollo y \/ o historia social<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_4_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.4' type='checkbox'  value='Registros educativos'  id='choice_8_4_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_4_4' id='label_8_4_4' class='gform-field-label gform-field-label--type-inline'>Registros educativos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_4_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.5' type='checkbox'  value='Notas de progreso y tratamiento o informe de cierre'  id='choice_8_4_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_4_5' id='label_8_4_5' class='gform-field-label gform-field-label--type-inline'>Notas de progreso y tratamiento o informe de cierre<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_8_4_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_4.6' type='checkbox'  value='Otro'  id='choice_8_4_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_4_6' id='label_8_4_6' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_5'>Para \/ De:<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_8_5' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_8_6\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half Witness field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_6'>Tel\u00e9fono:<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_8_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_8_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Su relaci\u00f3n con el cliente:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_7'>\n\t\t\t<div class='gchoice gchoice_8_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Yo soy el cliente'  id='choice_8_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_7_0' id='label_8_7_0' class='gform-field-label gform-field-label--type-inline'>Yo soy el cliente<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Padre \/ tutor legal'  id='choice_8_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_7_1' id='label_8_7_1' class='gform-field-label gform-field-label--type-inline'>Padre \/ tutor legal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Representante personal'  id='choice_8_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_7_2' id='label_8_7_2' class='gform-field-label gform-field-label--type-inline'>Representante personal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_7_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Otro'  id='choice_8_7_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_7_3' id='label_8_7_3' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_8_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >La informaci\u00f3n a divulgar se usar\u00e1 con el siguiente prop\u00f3sito:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_8_8'>\n\t\t\t<div class='gchoice gchoice_8_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Planear tratamiento o programa adecuado'  id='choice_8_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_8_0' id='label_8_8_0' class='gform-field-label gform-field-label--type-inline'>Planear tratamiento o programa adecuado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Continuar tratamiento o programa adecuado'  id='choice_8_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_8_1' id='label_8_8_1' class='gform-field-label gform-field-label--type-inline'>Continuar tratamiento o programa adecuado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_8_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Determinar eligibilidad para bene\ufb01cios o programas'  id='choice_8_8_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_8_2' id='label_8_8_2' class='gform-field-label gform-field-label--type-inline'>Determinar eligibilidad para bene\ufb01cios o programas<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_8_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Revisi\u00f3n de caso'  id='choice_8_8_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_8_3' id='label_8_8_3' class='gform-field-label gform-field-label--type-inline'>Revisi\u00f3n de caso<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_8_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Actualizaci\u00f3n de archivos'  id='choice_8_8_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_8_4' id='label_8_8_4' class='gform-field-label gform-field-label--type-inline'>Actualizaci\u00f3n de archivos<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_8_8_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Otro'  id='choice_8_8_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_8_8_5' id='label_8_8_5' class='gform-field-label gform-field-label--type-inline'>Otro<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_8_9\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Entiendo que esta informaci\u00f3n puede estar protegida por el T\u00edtulo 42 (C\u00f3digo de Reglas Federales de Privacidad de Informaci\u00f3n de Salud de Identificaci\u00f3n Individual, Partes 160 y 164) y el T\u00edtulo 45 (Reglas Federales de Confidencialidad de los Registros de Pacientes de Abuso de Drogas y Alcohol, Cap\u00edtulo 1, Parte 2 ), m\u00e1s las leyes estatales aplicables. Adem\u00e1s, entiendo que la informaci\u00f3n revelada al destinatario puede no estar protegida por estas pautas si no es un proveedor de atenci\u00f3n m\u00e9dica cubierto por las normas estatales o federales. <br><br>\n\nEntiendo que esta autorizaci\u00f3n es voluntaria, y puedo revocar este consentimiento en cualquier momento mediante notificaci\u00f3n por escrito, y luego (algunos estados var\u00edan, generalmente un a\u00f1o), este consentimiento caducar\u00e1 autom\u00e1ticamente. Se me ha notificado qu\u00e9 informaci\u00f3n se divulgar\u00e1, su prop\u00f3sito y qui\u00e9n la recibir\u00e1. Entiendo que tengo derecho a recibir una copia de esta autorizaci\u00f3n. Entiendo que tengo derecho a negarme a firmar esta autorizaci\u00f3n. <br><br>\n\nSi usted es el tutor legal o el representante designado por el tribunal para el cliente, adjunte una copia de esta autorizaci\u00f3n para recibir esta informaci\u00f3n m\u00e9dica protegida.<\/div><div id=\"field_8_10\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_8_10'>Doy consentimiento para compartir la informaci\u00f3n proporcionada en este formulario.<\/label><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_8_10_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input type='hidden' class='gform_hidden' name='input_8_10_valid' id='input_8_10_valid' \/><canvas id='input_8_10' width='300' 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