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DOSES 114AR Rev. 07/2013 State of Utah Department of Workforce Services AUTHORIZATION TO DISCLOSE MEDICAL ELIGIBILITY INFORMATION Customer Name Social Security # / / Case # Date of Birth D02914001820101
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What is authorization to disclose health?
Authorization to disclose health is a legal document that allows an individual or organization to share a person's health information with a specified party or parties.
Who is required to file authorization to disclose health?
Anyone who wants to share someone's health information with a third party, including healthcare providers, insurers, researchers, or individuals themselves, may be required to file authorization to disclose health.
How to fill out authorization to disclose health?
To fill out authorization to disclose health, one needs to provide the necessary information, such as the individual's name, the authorized recipient's name, the purpose of the disclosure, the specific information to be disclosed, and any limitations or expiration dates.
What is the purpose of authorization to disclose health?
The purpose of authorization to disclose health is to protect an individual's privacy and ensure that their health information is only shared with authorized parties for specific purposes as stated in the document.
What information must be reported on authorization to disclose health?
The information that must be reported on authorization to disclose health includes the individual's name, contact information, the authorized recipient's name, purpose of disclosure, specific information to be disclosed, any limitations or expiration dates, and any other required details as per the applicable regulations.
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