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This document authorizes the University of Utah Health Sciences Development Staff to use protected health information for communication and fundraising purposes, specifying the types of information
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How to fill out authorization for form use
How to fill out Authorization for the Use of Protected Health Information for Fundraising and Communication
01
Obtain the Authorization form from your healthcare provider or organization.
02
Read the instructions carefully to ensure you understand the purpose of the form.
03
Fill out the patient's information, including name, date of birth, and contact details.
04
Specify the type of protected health information (PHI) that can be used for fundraising and communication.
05
Indicate the purpose of the authorization, specifically for fundraising and communication purposes.
06
Provide a description of how the information will be used and shared.
07
Include the expiration date for the authorization, or indicate that it will remain in effect until revoked.
08
Sign and date the form to confirm consent, ensuring that both the patient and any required witnesses or guardians sign if applicable.
09
Submit the completed form to the relevant healthcare organization or fundraising department.
Who needs Authorization for the Use of Protected Health Information for Fundraising and Communication?
01
Patients who wish to allow their protected health information to be used for fundraising and communication purposes.
02
Healthcare organizations and providers needing authorization to use PHI for their marketing and fundraising efforts.
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What is Authorization for the Use of Protected Health Information for Fundraising and Communication?
Authorization for the Use of Protected Health Information for Fundraising and Communication is a legal document that allows healthcare organizations to use and disclose a patient's protected health information (PHI) for the purposes of fundraising and communication efforts.
Who is required to file Authorization for the Use of Protected Health Information for Fundraising and Communication?
Healthcare providers, hospitals, and other covered entities that seek to use patients' protected health information for fundraising and communication are required to obtain and file this authorization.
How to fill out Authorization for the Use of Protected Health Information for Fundraising and Communication?
To fill out the authorization, individuals must provide their name, the specific information to be used, the purpose of the disclosure, and the recipient of the information. It is also important to include the patient's signature and date.
What is the purpose of Authorization for the Use of Protected Health Information for Fundraising and Communication?
The purpose of this authorization is to ensure that patients have control over their protected health information and consent to its use for marketing or fundraising purposes, thereby promoting transparency and trust in healthcare relationships.
What information must be reported on Authorization for the Use of Protected Health Information for Fundraising and Communication?
The information that must be reported includes the patient's name, the specific PHI to be disclosed, the purpose of the disclosure, the recipient's name, an expiration date or event for the authorization, and the patient's signature and date.
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