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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Developed for Texas Health & Safety Code S 181.154(d) effective June 2013Please read this entire form before signing and complete all the sections
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To fill out dates of service requested, follow these steps:
02
Start by noting down the start date of the service requested.
03
Write the end date of the service requested.
04
Ensure that the dates are accurate and not overlapping with any other service periods.
05
Double-check the dates before submitting the information.

Who needs dates of service requested?

01
Various individuals or entities may need dates of service requested, including:
02
- Employers or hiring managers for job applications
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- Service providers for scheduling and planning purposes
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- Government agencies for eligibility determination
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Dates of service requested refer to the specific dates that services were provided or rendered.
Healthcare providers, medical facilities, and insurance companies may be required to file dates of service requested.
Dates of service requested can be filled out by entering the start date and end date of the services provided.
The purpose of dates of service requested is to accurately document when services were provided for billing or insurance purposes.
Dates of service requested may require reporting the type of service, provider information, patient information, and any relevant diagnosis or procedure codes.
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