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AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI) FLORIDA HEALTH CARE PLANS P.O. BOX 9910 DAYTONA BEACH, FL 32120 PLEASE FAX MEDICAL RECORDS TO: 3864815009 OR 8884274544FHCP Medical Record

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How to fill out authorization to release protected

01

Fill in the requester's contact information including name, address, and phone number.

02

Provide the name of the person or organization that will be releasing the protected information.

03

Specify the type of information that is being released.

04

Include the purpose or reason for releasing the protected information.

05

Sign and date the authorization form.

Who needs authorization to release protected?

01

Individuals or organizations who are requesting access to protected information need authorization to release protected.

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What is authorization to release protected?

Authorization to release protected is a document that allows an individual or entity to share protected information with a specific person or organization.

Who is required to file authorization to release protected?

The individual or entity holding the protected information is required to file authorization to release protected.

How to fill out authorization to release protected?

Authorization to release protected can be filled out by providing the necessary information about the parties involved, the specific information to be released, and the purpose of the release.

What is the purpose of authorization to release protected?

The purpose of authorization to release protected is to ensure that sensitive information is only shared with authorized parties and for specified reasons.

What information must be reported on authorization to release protected?

Information such as the name of the parties involved, the specific information to be released, the purpose of the release, and the expiration date of the authorization must be reported on authorization to release protected.

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