UAB Health System Authorization for Use or Disclosure of Information 2018-2025 free printable template

PATIENT ACCESS/AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT INFORMATION Iherebyrequest/authorizetheuseordisclosureofmyprotectedhealthinformation(PHI)asdescribedbelow. ThisRequest/Authorization includes anyinformationrelatingtodrug,

How to fill out uab university birmingham system authorization disclosure form

How to fill out UAB Health System Authorization for Use or Disclosure

1. Obtain the UAB Health System Authorization for Use or Disclosure form from the UAB Health System website or through patient services.
2. Fill in the patient's name, date of birth, and contact information at the top of the form.
3. Specify the information to be disclosed by checking the appropriate boxes (e.g., medical records, billing information).
4. Indicate the purpose of the disclosure (e.g., continuity of care, personal use) in the designated section.
5. Provide the name of the person or entity to whom the information will be disclosed.
6. Set a date or event that will terminate the authorization, if applicable.
7. Sign and date the form at the bottom, ensuring to include your relationship to the patient if you are signing on their behalf.
8. Submit the completed form to the appropriate department at UAB Health System as indicated on the form.

Who needs UAB Health System Authorization for Use or Disclosure?

1. Patients who wish to share their medical information with other healthcare providers.
2. Individuals who are involved in the patient's care, such as family members or legal guardians, who require access to the patient's health information.
3. Third-party entities that require health information for legal, research, or insurance purposes.

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What is UAB Health System Authorization for Use or Disclosure?

UAB Health System Authorization for Use or Disclosure is a legal document that grants permission to UAB Health System to share a patient's medical information with specified individuals or entities.

Who is required to file UAB Health System Authorization for Use or Disclosure?

Patients or their legal representatives are required to file the UAB Health System Authorization for Use or Disclosure to permit the sharing of their medical information.

How to fill out UAB Health System Authorization for Use or Disclosure?

To fill out the UAB Health System Authorization for Use or Disclosure, individuals must provide their personal information, specify who is authorized to receive the information, indicate what information can be disclosed, and sign the form.

What is the purpose of UAB Health System Authorization for Use or Disclosure?

The purpose of the UAB Health System Authorization for Use or Disclosure is to ensure that patient privacy is protected while allowing for the necessary sharing of medical information for treatment, billing, or other legitimate purposes.

What information must be reported on UAB Health System Authorization for Use or Disclosure?

The information that must be reported includes the patient's name, date of birth, the specific medical information to be disclosed, the names of individuals or entities receiving the information, and the duration of the authorization.