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Form # 4 PHI Release Form SHIRAZ C. SHAH PHYSICIAN PC 99 EAST STATE STREET GLOVERSVILLE, NY 12078 PATIENT AUTHORIZATION FOR PRACTICE TO RELEASE PROTECTED HEALTH INFORMATION TO THE THIRD PARTIES By

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What is phi release form 4?

Phi release form 4 is a document that allows the disclosure of protected health information (PHI) to a specific individual or entity.

Who is required to file phi release form 4?

Phi release form 4 is typically required to be filed by healthcare providers or organizations that need to release PHI to a third party.

How to fill out phi release form 4?

Phi release form 4 requires the individual's or patient's information, the recipient's information, the purpose of the disclosure, and any restrictions on the information being shared.

What is the purpose of phi release form 4?

The purpose of phi release form 4 is to ensure that PHI is being disclosed in accordance with the Health Insurance Portability and Accountability Act (HIPAA) regulations and that patient privacy is protected.

What information must be reported on phi release form 4?

Phi release form 4 typically requires the patient's name, date of birth, medical record number, the information being disclosed, the recipient's name, and the purpose of the disclosure.

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