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Brighton Hill Pediatrics 151 Intrepid Lane, Syracuse, NY 13205 Phone (315) 4698191 Fax (315) 4102029Authorization for the Release of Protected Health Information Patient Name: Date of Birth: / / (PLEASE
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What is what abouthttpswwwbhpedscommedia1115release-of-protected-health-information-inbound-formpdf?
This form is used to release protected health information.
Who is required to file what abouthttpswwwbhpedscommedia1115release-of-protected-health-information-inbound-formpdf?
Patients or their authorized representatives are required to file this form.
How to fill out what abouthttpswwwbhpedscommedia1115release-of-protected-health-information-inbound-formpdf?
The form must be completed with the patient's information, the type of information being released, and the recipient's details.
What is the purpose of what abouthttpswwwbhpedscommedia1115release-of-protected-health-information-inbound-formpdf?
The purpose of this form is to authorize the disclosure of protected health information.
What information must be reported on what abouthttpswwwbhpedscommedia1115release-of-protected-health-information-inbound-formpdf?
The form must include the patient's personal information, the information being released, and the recipient's details.
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