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Patient Authorization FOR CLINIC TO RELEASE PROTECTED HEALTH INFORMATION TO THIRD PARTY/PARTIES By signing this authorization, I authorize Allergy & Asthma Specialists, P.A. to use and or disclose

How to fill out patient-authorization-for-usedisclosure-form-091713doc table of tasks

How to fill out the Patient Authorization for Use/Disclosure Form:

1. Start by downloading the Patient Authorization for Use/Disclosure Form (Form 091713doc) from the appropriate healthcare provider or organization's website.
2. Once downloaded, open the form using a compatible software that allows you to fill out PDF forms.
3. Begin by entering your personal information in the designated fields. This typically includes your full name, date of birth, address, and contact information.
4. Next, provide the information about the healthcare provider or organization that will be receiving or disclosing your medical information. This may include their name, address, and contact information.
5. Read through each section of the form carefully to understand the purpose of the authorization and any specific restrictions or limitations that may apply.
6. Determine the type of authorization you wish to grant. In most cases, this would be an authorization to disclose your medical information to a specific third party or for a particular purpose.
7. Specify the duration for which the authorization is valid. This could be a one-time authorization or have an expiration date.
8. If there are any specific limitations or conditions you wish to place on the use/disclosure of your medical information, clearly state them in the designated section of the form.
9. Review the form once again to ensure that all the information provided is accurate and complete.
10. Finally, sign and date the form in the appropriate fields.

Who needs the Patient Authorization for Use/Disclosure Form:

1. Patients who want to grant authorization for their medical information to be disclosed or shared with a specific individual or organization.
2. Healthcare providers or organizations that require a patient's authorization to disclose or use their medical information for a specific purpose.
3. Third parties or entities that need access to a patient's medical information and are required to have proper authorization in order to obtain it.

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