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CENTENNIAL PEAKS HOSPITAL2255 South 88th St. Louisville, Colorado 80027 Phone 3036739990 Fax 3036662097 AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Purpose: Verbal or written mutual exchange
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Start by opening the authorization-to-release-phi-w-part-2-sud-012020doc form on your computer.
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Carefully read through the form to understand the information it requests.
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Begin filling out the form by providing your personal information, such as your name, address, and contact details.
04
Next, indicate the specific date range for which the authorization is valid.
05
Identify the purpose of the authorization, including the individual or organization to whom the PHI will be released.
06
Specify the exact PHI elements that will be disclosed.
07
Determine any limitations or restrictions on the use or disclosure of the PHI.
08
If necessary, provide any additional information or documentation required.
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Carefully review the form to ensure accuracy and completeness.
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Sign and date the form to signify your consent.
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Make a copy of the completed form for your records, if desired.
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Submit the authorization form to the appropriate recipient or organization.

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Anyone who needs to release protected health information (PHI) to a specific individual or organization may need authorization-to-release-phi-w-part-2-sud-012020doc. This includes healthcare providers, insurers, researchers, legal entities, and individuals who have access to PHI and need to share it for purposes such as treatment, payment, healthcare operations, research, or legal proceedings.
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Authorization to release PHI (Protected Health Information) with Part 2 Substance Use Disorder (SUD) information released on January 2020.
Healthcare providers or facilities handling PHI and SUD information.
The form needs to be completed with the patient's details, the specific information to be released, the recipient's information, and the purpose of release.
To authorize the release of PHI along with Part 2 SUD information to a specified recipient for a specific purpose.
Patient's personal information, details of the information to be released, recipient information, and the purpose of release.
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