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FALMOUTH Orthopedic CENTER AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI) This authorization is for use or disclosure of protected health information pertaining to: Patient Name: (Maiden

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How to fill out authorization to release information

01

Start by clearly stating your identification information at the top of the authorization form, such as your name, address, date of birth, and social security number.

02

Identify the specific information that you authorize to be released. This can include medical records, financial information, educational records, etc.

03

Specify the purpose for which the information is being released. This could be for legal proceedings, healthcare treatment, employment purposes, etc.

04

Include the name and address of the person or organization to whom the information is being released.

05

Indicate the timeframe for which the authorization is valid. You can specify a specific date range or specify that it remains valid until revoked.

06

Sign and date the authorization form, and provide any additional required contact information.

07

Keep a copy of the authorization for your records before submitting it to the appropriate person or organization.

Who needs authorization to release information?

01

Authorization to release information is typically needed by individuals or organizations that require access to someone's personal information. This can include healthcare providers, insurance companies, employers, educational institutions, government agencies, and legal representatives.

02

In general, anyone who wants to obtain another person's personal information that is protected by privacy laws or regulations will need an authorization to release information.

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