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Chapel Hill Pediatric Psychology, P.A. 205 Sage Road, Suite 201, Chapel Hill, NC 27514 Telephone: (919) 9424166 Fax: (919) 9428693 PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH

How to fill out patient authorization for use

How to fill out patient authorization for use:

1. Begin by entering the patient's full name, date of birth, and contact information in the designated fields on the form.
2. Next, provide the name of the healthcare facility or organization requesting the patient's authorization.
3. Specify the purpose of the patient's authorization, such as for treatment, research, or release of medical records.
4. Indicate the specific information or medical records that the patient authorizes to be disclosed, ensuring clarity and accuracy.
5. If the patient has any limitations or restrictions on the use or disclosure of their medical information, include those details on the form.
6. The patient should then carefully review the authorization form, ensuring they understand its terms and implications.
7. Once reviewed, the patient must date and sign the authorization form.
8. If the patient is unable to provide their own signature, there should be a section on the form for a designated representative to sign on their behalf.
9. Finally, the completed authorization form should be submitted to the appropriate healthcare facility or organization, following their specified instructions.

Who needs patient authorization for use:

1. Healthcare providers: Doctors, nurses, hospitals, and other healthcare professionals may require patient authorization to access, use, or disclose their medical information for treatment purposes or to share with other providers involved in the patient's care.
2. Researchers: When conducting medical or scientific research involving human subjects, researchers typically need patient authorization to access and use their medical information for study purposes.
3. Insurance companies: Insurance companies may request patient authorization to access their medical records and determine eligibility, coverage, or claims processing.
4. Legal entities: Attorneys, courts, and other legal entities may require patient authorization to obtain medical records for legal proceedings.
5. Government agencies: Certain government agencies, such as public health departments or regulatory bodies, may require patient authorization to access or use their medical information for reporting, tracking, or compliance purposes.

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What is patient authorization for use?

Patient authorization for use is a legal document signed by a patient that gives permission for their personal health information to be used or disclosed for specific purposes.

Who is required to file patient authorization for use?

Healthcare providers, insurance companies, and other entities that handle patient health information are required to file patient authorization for use.

How to fill out patient authorization for use?

Patient authorization for use can be filled out by entering the patient's information, specifying the purpose of the use or disclosure, and obtaining the patient's signature.

What is the purpose of patient authorization for use?

The purpose of patient authorization for use is to protect patient privacy and ensure that their health information is only used for authorized purposes.

What information must be reported on patient authorization for use?

Patient authorization for use should include the patient's name, contact information, specific information to be disclosed, purpose of disclosure, and expiration date of authorization.