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AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)SIERRA VIEW MEDICAL CENTERPatient name: Date of birth: Social security number: XXXIX Phone number: Email address: Mailing address: City/State/Zip
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How to fill out 014104 authorization for release

01
To fill out the 014104 authorization for release form, follow these steps:
02
Start by providing your personal information in the top section of the form. This includes your name, address, phone number, and email address.
03
Next, write down the date on which you are filling out the form.
04
In the 'Release of Information' section, specify the type of information you are authorizing to release. This can include medical records, financial information, or any other relevant documents.
05
Indicate the specific purpose for which the information will be released. Provide as much detail as possible to ensure clarity.
06
If you want to authorize release of information to a specific individual or organization, provide their name, address, and contact details in the 'Recipient Information' section.
07
Sign and date the form at the bottom to validate your authorization.
08
Make a copy of the completed form for your records before submitting it to the appropriate authority.
09
Note: It is important to read the instructions provided with the form to ensure that you provide accurate and complete information.

Who needs 014104 authorization for release?

01
The 014104 authorization for release form may be needed by individuals or organizations who require access to specific information. This can include healthcare providers, insurance companies, legal professionals, or any other party that requires authorization to access and use certain information. The exact requirements for this form may vary depending on the specific situation and jurisdiction.
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The 014104 authorization for release is a form used to authorize the release of information.
Any individual or entity seeking to release information is required to file the 014104 authorization for release form.
To fill out the 014104 authorization for release form, you need to provide your personal information, specify the information you are authorizing for release, and sign the form.
The purpose of the 014104 authorization for release form is to grant permission for the release of specified information to a designated individual or entity.
The 014104 authorization for release form should include details of the information being released, the purpose for release, and the recipient of the information.
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