Get the free Authorization for Release of Protected Health Information

This document serves as an authorization for the release of protected health information from Ohio County Hospital Corporation, detailing patient information and terms for disclosure.

How to fill out authorization for release of

How to fill out Authorization for Release of Protected Health Information

1. Obtain the Authorization for Release of Protected Health Information form from the healthcare provider or organization.
2. Fill in the patient's full name, address, date of birth, and any other identifying information required.
3. Specify the information to be released, including dates of service, types of records, and specific details needed.
4. Indicate the purpose of the release, such as medical treatment, legal reasons, or personal use.
5. Provide the name and contact information of the individual or organization to whom the information will be sent.
6. Specify the duration for which the authorization is valid; some forms may require an expiration date.
7. Include any restrictions or limitations on the release of information, if applicable.
8. Sign and date the form, ensuring that the signature matches the patient's name.
9. If applicable, include a witness signature or the signature of a legal guardian or representative.
10. Submit the completed form to the healthcare provider or organization processing the request.

Who needs Authorization for Release of Protected Health Information?

1. Patients seeking to transfer their medical records to another provider.
2. Individuals requesting their own health information for personal records.
3. Family members or legal guardians of patients who require access to the patient's health information.
4. Attorneys or legal representatives seeking medical records for legal cases.
5. Researchers or organizations that require de-identified information for studies, though specific authorizations may be needed.

People Also Ask about

What is required for releasing protected health information?

A covered entity must obtain the individual's written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

How do you write an authorization to release information?

Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

How do I give someone a HIPAA authorization?

A HIPAA-compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.

What is written authorization for PHI?

HIPAA stipulates that there has to be a written authorization for every use or disclosure of PHI not required or permitted by the HIPAA Privacy Rule. In addition, the retraction of HIPAA authorization also has to be written.

For pdfFiller’s FAQs

What is Authorization for Release of Protected Health Information?

Authorization for Release of Protected Health Information is a legal document that allows a healthcare provider to share an individual's protected health information (PHI) with designated persons or organizations.

Who is required to file Authorization for Release of Protected Health Information?

Any individual or entity that wishes to access someone else's protected health information must file an Authorization for Release of Protected Health Information.

How to fill out Authorization for Release of Protected Health Information?

To fill out the Authorization for Release of Protected Health Information, provide the patient's details, specify the information to be disclosed, identify the recipients, state the purpose of the disclosure, and sign and date the form.

What is the purpose of Authorization for Release of Protected Health Information?

The purpose of Authorization for Release of Protected Health Information is to ensure that individuals have control over their personal health information and to comply with legal requirements regarding the sharing of such information.

What information must be reported on Authorization for Release of Protected Health Information?

Information that must be reported includes the patient's name, the specific information to be released, the names of the individuals or entities receiving the information, the purpose of the release, and the expiration date of the authorization.