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Carla Bradshaw, PhD Clinical Psychologist, WA #1223 1104 Market Street Kirkland, WA 98033 425-827-7111 425-889-8362 (fax) Authorization Form to Obtain/Release of Information This form when completed

How to fill out release of information

How to fill out a release of information:

1. Obtain the form: Start by getting a copy of the release of information form. This form can usually be obtained from the organization or healthcare provider that is overseeing the release of your information.
2. Read the instructions: Take the time to carefully read through the instructions provided on the form. This will help ensure that you understand the process and what is required of you.
3. Provide personal information: Begin by providing your personal information such as your name, address, date of birth, and contact details. Make sure to accurately fill out all the required fields.
4. Specify the information to be released: Indicate the specific information that you would like to have released. This could include medical records, test results, or any other relevant documents. Be as specific and detailed as possible to avoid any confusion.
5. Identify the recipient: Clearly state the name and contact information of the individual or organization that you authorize to receive your information. This could be a healthcare provider, insurance company, or any relevant third party.
6. Mention the purpose of the release: Provide a brief explanation of why you are authorizing the release of your information. This could be for medical treatment, insurance purposes, or any other legitimate reason. Make sure to be clear and concise in your explanation.
7. Sign and date the form: Once you have completed all the necessary sections, sign and date the form. By doing so, you are officially authorizing the release of your information.

Who needs a release of information:

1. Patients: As a patient, you may need a release of information when you want to share your medical records or other personal information with a specific individual or organization. This is often necessary for medical treatment, insurance claims, or legal purposes.
2. Healthcare providers: Healthcare providers may require a release of information when they need to share your medical records with other healthcare professionals involved in your care. This ensures a seamless transfer of information and allows for comprehensive treatment.
3. Insurance companies: Insurance companies may request a release of information in order to process claims or verify the medical necessity of certain treatments or procedures. This allows them to access relevant medical information to make informed decisions.

In summary, filling out a release of information requires obtaining the form, reading the instructions, providing personal information, specifying the information to be released, identifying the recipient, mentioning the purpose of release, and signing and dating the form. Both patients, healthcare providers, and insurance companies may require release of information for various purposes.

For pdfFiller’s FAQs

What is release of information?

Release of information is the process of providing access to protected health information (PHI) to authorized individuals or entities.

Who is required to file release of information?

Healthcare providers, facilities, insurance companies, and other covered entities are required to file release of information.

How to fill out release of information?

Release of information forms typically require the individual's name, date of birth, specific information being released, purpose of release, and signatures.

What is the purpose of release of information?

The purpose of release of information is to ensure that PHI is only disclosed to authorized parties for the appropriate reasons.

What information must be reported on release of information?

Release of information forms typically require details such as the type of information being released, the reason for release, and signatures from both the individual requesting the release and the authorized party.

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