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L. Justin Wheeler, LIST NPI #1255695383 Offices at Blue Line Drive, Athens OH Client Name: DOB: / / 17 Blue Line Drive, Athens, Ohio 45701 7405925689 / FAX 7405937166 CONSENT FOR RELEASE OF CONFIDENTIAL

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How to fill out release of information

01

Step 1: Obtain the release of information form. This can be obtained from the healthcare provider, hospital, or insurance company.

02

Step 2: Read the release of information form carefully, making sure you understand all the information and instructions provided.

03

Step 3: Fill out your personal information in the designated spaces, including your full name, date of birth, address, and contact details.

04

Step 4: Specify the purpose for which you are authorizing the release of information. This can include medical treatment, insurance claims, or legal proceedings.

05

Step 5: Provide the name and contact information of the healthcare provider or institution from which you want the information to be released.

06

Step 6: Indicate the specific information you are authorizing to be released. You can be specific about the dates, types of records, or categories of information.

07

Step 7: Sign and date the release of information form to acknowledge your consent and authorization.

08

Step 8: Make a copy of the completed form for your records before submitting it to the designated recipient.

09

Step 9: Submit the release of information form to the healthcare provider, institution, or insurance company as instructed.

Who needs release of information?

01

Patients or individuals who wish to authorize the release of their personal health information to a third party, such as another healthcare provider, insurance company, or legal representative.

02

Individuals who require their medical records to be shared with another healthcare provider to ensure continuity of care.

03

Patients or individuals involved in insurance claims or legal proceedings that necessitate the disclosure of their medical information.

04

Healthcare professionals or organizations that require access to patient information for the purpose of providing appropriate care or treatment.

05

Insurance companies or legal representatives who need access to medical records to process claims or support legal cases.

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What is release of information?

Release of information is a process that allows for the disclosure of protected health information to authorized individuals or entities.

Who is required to file release of information?

Healthcare providers, insurance companies, and other covered entities are required to file release of information.

How to fill out release of information?

To fill out a release of information form, you typically need to provide your name, date of birth, the name of the person or entity receiving the information, and the specific information being released.

What is the purpose of release of information?

The purpose of release of information is to ensure that individuals' protected health information is disclosed only to authorized parties for legitimate purposes.

What information must be reported on release of information?

The information reported on a release of information form typically includes the individual's name, date of birth, the specific information to be released, and the name of the recipient.

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