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AUTHORIZATION FOR RELEASE PATIENT HEALTH INFORMATION ASU Health Services Medical Records Department P.O. Box 872104 Tempe, Arizona 85287-2104 Phone: 480-965-1359 Fax: 480-965-6531 Action Requested:
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How to fill out authorization for release patient
How to fill out authorization for release patient?
01
Obtain the necessary form: Start by obtaining the authorization for release patient form from the healthcare facility where the patient is receiving treatment. This form may also be available online on the facility's website.
02
Patient identification: Fill out the patient's personal information accurately. This typically includes the patient's full name, date of birth, address, contact number, and any other identifying information required by the form.
03
Specify the purpose of the release: Clearly state the purpose for which the patient's information is being released. This could be for the transfer of medical records to another healthcare provider, for legal purposes, or any other valid reason. Be sure to provide specific details to avoid any confusion.
04
Specify the recipient of the information: Indicate the name, address, and contact information of the individual or organization who will be receiving the patient's information. This could be another healthcare facility, a legal representative, or any other authorized party.
05
Duration of authorization: State the specific time period during which the authorization for release patient is valid. This ensures that the patient's information is not released indefinitely and allows for proper control over the use of their medical records.
06
Signatures: The authorization form typically requires the signature of the patient or their legal representative. Ensure that the necessary signatures are provided and that they are dated appropriately. In some cases, witness signatures may also be required.
Who needs authorization for release patient?
Any individual, organization, or healthcare facility that requires access to a patient's medical records or personal health information may need authorization for release patient. This could include healthcare providers, insurance companies, legal representatives, researchers, or even the patient themselves if they wish to transfer their records to another facility. It is essential to follow the privacy and confidentiality regulations in your jurisdiction when handling patient information.
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