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AZ Touchstone Health Services Authorization for Release of Information 2019-2025 free printable template

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AUTHORIZATIONFORRELEASEOFINFORMATIONPLEASEPRINTCLEARLYANDCOMPLETEALLFIELDS PICKUPRELASEAVAILABLEAT15648 N. 35THE AVE PHOENIX, AZ 85053 MembersName CIS# AHC CCS# DateofBirthPerson/Agencyauthorizedtomakethedisclosure:TouchstoneHealthServices
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How to fill out AZ Touchstone Health Services Authorization for Release

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How to fill out AZ Touchstone Health Services Authorization for Release of Information

01
Begin by obtaining the AZ Touchstone Health Services Authorization for Release of Information form.
02
Fill in the patient's full name, address, and date of birth at the top of the form.
03
Specify the purpose of the authorization in the appropriate section.
04
Indicate the specific information that you are authorizing to be released (e.g., medical records, treatment history).
05
Provide the name and contact information of the individual or organization that will receive the information.
06
Include the duration for which the authorization is valid (e.g., specific date range or until revoked).
07
Review the form for accuracy and completeness.
08
Sign and date the form in the designated area. If filling for a minor, include a guardian's signature.
09
Provide a copy of the signed authorization to the recipient and keep a copy for your records.

Who needs AZ Touchstone Health Services Authorization for Release of Information?

01
Individuals seeking to share their medical information with another healthcare provider.
02
Patients giving permission for their health information to be disclosed for specific purposes, such as treatment or insurance claims.
03
Legal representatives acting on behalf of patients requiring access to health records.
04
Family members of patients who need to obtain information related to a loved one's healthcare.
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AZ Touchstone Health Services Authorization for Release of Information is a legal document that allows individuals to authorize the release of their medical and personal information to designated individuals or entities.
Any individual who wishes to grant permission for the release of their health information, or a legal guardian of a minor or disabled individual, is required to file this authorization.
To fill out the authorization, individuals need to provide their personal information, specify what information is to be released, identify the recipient of the information, and sign and date the form.
The purpose of this authorization is to ensure that individuals have control over their personal health information by allowing them to decide who can access or use it for treatment, payment, or other designated purposes.
The information that must be reported includes the individual's name and contact information, the nature of the information to be released, the purpose of the release, and the names of the individuals or entities authorized to receive the information.
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