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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Print patients legal name: Date of Birth: / / Address: Street Address City State Zip Code Phone Number: please circle: home cell workAlternate
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01
Start by writing the patient's first name in the designated field.
02
Proceed to write the patient's middle name, if applicable.
03
Write the patient's last name in the provided space.
04
Double-check the spelling of each name to ensure accuracy.
05
Ensure that the names are written in uppercase or lowercase letters as per the given instructions.
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Avoid using any nicknames or abbreviations while filling out the legal name section.
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If there are any suffixes or prefixes associated with the patient's name, include them accordingly.
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Complete all the required fields relating to the patient's legal name and move on to the next section.

Who needs print patients legal name?

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Anyone who is filling out a form or document pertaining to a patient's personal information needs to provide the patient's legal name.
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Print patients legal name refers to the full legal name of the patient.
Healthcare providers or facilities are required to file print patients legal name.
Print patients legal name should be filled out with the patient's first name, middle name (if applicable), and last name as stated on their legal identification.
The purpose of print patients legal name is to accurately identify the patient in medical records and documentation.
The information reported on print patients legal name includes the patient's full legal name as per their identification documents.
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