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AUTHORIZATION FOR DISCLOSURE OF ANSI BUILDING 1340 Boston Street Boston MA 02215 TEL 617.267.0900 WEB fenwayhealth.org Protected Health Information PATIENT NAME ADDRESS PHONE NUMBER SOCIAL SECURITY

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How to fill out MA Fenway Health Authorization for Disclosure of Protected Health

1. Obtain the MA Fenway Health Authorization for Disclosure of Protected Health form from the Fenway Health website or request a copy from the office.
2. Fill in your name, address, and contact information in the designated sections.
3. Specify the individual or organization to whom your health information will be disclosed.
4. Clearly state the purpose of the disclosure.
5. Indicate the specific information that you authorize to be disclosed (e.g., medical records, mental health records, etc.).
6. Provide the effective dates for the authorization, if applicable.
7. Sign and date the form at the bottom.
8. If required, have a witness or legal guardian sign the form (if the patient is a minor or unable to sign).
9. Submit the completed form to Fenway Health via the method specified on the form.

Who needs MA Fenway Health Authorization for Disclosure of Protected Health?

1. Patients seeking to allow Fenway Health to share their protected health information with third parties.
2. Individuals needing to provide their health records to healthcare providers or insurance companies.
3. Legal representatives or guardians of patients who require access to medical information.

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What is MA Fenway Health Authorization for Disclosure of Protected Health?

The MA Fenway Health Authorization for Disclosure of Protected Health is a form that allows individuals to permit the sharing of their protected health information with designated parties.

Who is required to file MA Fenway Health Authorization for Disclosure of Protected Health?

Patients of Fenway Health who wish to authorize the release of their protected health information to third parties are required to file this authorization.

How to fill out MA Fenway Health Authorization for Disclosure of Protected Health?

To fill out the form, individuals must provide their personal information, specify the information to be disclosed, identify the recipients, and sign and date the authorization.

What is the purpose of MA Fenway Health Authorization for Disclosure of Protected Health?

The purpose of the authorization is to ensure that patients can control who has access to their health information and to comply with legal requirements for sharing such information.

What information must be reported on MA Fenway Health Authorization for Disclosure of Protected Health?

The information required includes the patient's name, date of birth, details of the information being disclosed, the purpose of disclosure, recipient details, and the patient's signature.