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AUTHORIZATION FOR RELEASE OF INFORMATION I authorize Green Hills Pediatric Associate (GPA) to use and/or disclose my children/children's protected health information (PHI) to: Office/Doctors Name:

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What is authorizaton-for-release-of-information-from-ghpadoc?

Authorization for release of information from GHPADoc is a form that allows GHPADoc to release information about a patient to authorized individuals or organizations.

Who is required to file authorizaton-for-release-of-information-from-ghpadoc?

Patients or their legal representatives are required to file authorization for release of information from GHPADoc.

How to fill out authorizaton-for-release-of-information-from-ghpadoc?

To fill out authorization for release of information from GHPADoc, the patient or legal representative must provide their personal information, specify the information to be released, and sign the form.

What is the purpose of authorizaton-for-release-of-information-from-ghpadoc?

The purpose of authorization for release of information from GHPADoc is to ensure that patient information is only shared with authorized individuals or organizations.

What information must be reported on authorizaton-for-release-of-information-from-ghpadoc?

Authorization for release of information from GHPADoc must include the patient's name, date of birth, the information to be released, the purpose of the release, and the duration of the authorization.

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