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Central Maine Healthcare Biometric Screen Authorization of Treatment and Release Last Name: First Name: DOB: / / (mm/dd/YYY)Gender: Male or Female Street Address: City, State Zip Code: Telephone Number:

How to fill out cmh-privacy-authorization-of-treatment-and-release-10-30-14docx

How to fill out cmh-privacy-authorization-of-treatment-and-release-10-30-14docx:

1. Start by opening the cmh-privacy-authorization-of-treatment-and-release-10-30-14docx document on your computer.
2. Read through the entire document carefully to understand its purpose and the information it requires from you.
3. Begin by entering your personal information, such as your full name, date of birth, and contact details, in the designated fields.
4. Next, provide the name and contact information of the healthcare provider or organization that will be releasing your medical information.
5. Specify the purpose for which the information is being released by selecting the appropriate options or providing a detailed explanation.
6. Determine the specific medical information that you authorize to be released. This can include records, test results, treatment plans, and other relevant documents.
7. Indicate the start and end dates for the authorization, if applicable, or explicitly state if the authorization has no expiration date.
8. Review the document thoroughly to ensure all the information you provided is accurate and complete.
9. If required, sign and date the document in the designated areas, indicating your consent and understanding.
10. Make a copy of the completed document for your records and submit the original to the concerned healthcare provider or organization.

Who needs cmh-privacy-authorization-of-treatment-and-release-10-30-14docx:

1. Patients who wish to authorize the release of their medical information to specific individuals or organizations.
2. Healthcare providers or organizations that require explicit consent from patients before disclosing their medical information to others.
3. Individuals who are participating in research studies or clinical trials may be asked to sign the cmh-privacy-authorization-of-treatment-and-release-10-30-14docx to allow the sharing of their medical data for research purposes.

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