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1-800-AEL-8888 NAME SEX M F MR# *DTMR109* MR-109 AEL 9/2005 AGE / DATE OF BIRTH AUTHORIZATION TO RELEASE/OBTAIN PATIENT INFORMATION ACCOUNT# (PATIENT PLATE OR PRINT) This authorizes The Children s
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What is authorization to release/obtain patient?
Authorization to release/obtain patient is a legal document that allows healthcare providers to disclose a patient's medical information to another party or obtain medical information from another provider.
Who is required to file authorization to release/obtain patient?
The patient or the patient's legal guardian is required to file authorization to release/obtain patient.
How to fill out authorization to release/obtain patient?
To fill out authorization to release/obtain patient, the patient or legal guardian must provide their personal information, specify the information to be released/obtained, and sign the document.
What is the purpose of authorization to release/obtain patient?
The purpose of authorization to release/obtain patient is to ensure that patient's medical information is only shared with authorized individuals and institutions for proper medical treatment.
What information must be reported on authorization to release/obtain patient?
The information reported on authorization to release/obtain patient includes patient's name, date of birth, medical record number, type of information to be released/obtained, and the duration of authorization.
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