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MultiCare Authorization to Use and Disclose Protected Health Information 2017-2025 free printable template

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All portions of this form must be completed to constitute a valid authorization for release of health information under the Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.
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How to fill out MultiCare Authorization to Use and Disclose Protected

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How to fill out MultiCare Authorization to Use and Disclose Protected Health

01
Obtain the MultiCare Authorization form from the MultiCare website or your healthcare provider's office.
02
Fill in the patient's name, date of birth, and contact information at the top of the form.
03
Specify the purpose of the authorization (e.g., treatment, payment, or healthcare operations).
04
List the records or information to be disclosed, including dates of service if applicable.
05
Identify the person or organization authorized to receive the information.
06
Indicate the date range for which the authorization is valid, if necessary.
07
Sign and date the authorization at the bottom of the form.
08
Provide the completed authorization form to the designated recipient or healthcare provider.

Who needs MultiCare Authorization to Use and Disclose Protected Health?

01
Patients who want their health information shared with other healthcare providers.
02
Individuals seeking to release medical records for insurance purposes.
03
Caregivers or family members who need access to a patient's health information.
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MultiCare Authorization to Use and Disclose Protected Health is a legal document that allows healthcare providers to share a patient's protected health information (PHI) with third parties for specified purposes, such as treatment, payment, or healthcare operations.
Patients or their legally authorized representatives are required to file the MultiCare Authorization to Use and Disclose Protected Health in order to permit healthcare providers to share their protected health information with others.
To fill out the MultiCare Authorization, provide the patient's information, specify the entities authorized to receive disclosure, describe the purpose of the disclosure, and sign and date the form. Ensure that all required fields are completed accurately.
The purpose of the MultiCare Authorization is to obtain patient consent for the sharing of their protected health information with specified individuals or entities, ensuring that the patient's rights to privacy are respected while facilitating necessary communication in their care.
The information that must be reported on the MultiCare Authorization includes the patient's name, date of birth, the specific information to be disclosed, the names of the individuals or organizations authorized to receive the information, the purpose of the disclosure, and the patient's signature and date.
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