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SUMMIT FAMILY PRACTICE, LLC 2741 DEBARK RD. STE C308 ANCHORAGE, AK 99508 PH 907 272 3366 FAX 907 272 0269 AUTHORIZATION TO RELEASE / OBTAIN MEDICAL RECORDS PATIENTS NAME: DATE OF BIRTH: Current Address:
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What is release of information 10-10?
Release of information 10-10 is a form used to authorize the disclosure of personal health information.
Who is required to file release of information 10-10?
Any individual or entity that wishes to share an individual's personal health information.
How to fill out release of information 10-10?
Fill out the form with the required personal information, specify the information to be disclosed, and sign the authorization.
What is the purpose of release of information 10-10?
The purpose of release of information 10-10 is to ensure that personal health information is only disclosed with the individual's explicit consent.
What information must be reported on release of information 10-10?
The form typically requires the individual's name, date of birth, specific information to be disclosed, recipient of the information, and expiration date of the authorization.
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