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HAWAII REGION MR #:Authorization for Verbal Release of Protected Health Information (PHI)Name: Sex/BD:Original: 5/03/07Revised: 12/06/07 Use BLACK ball point pen. Format: Date: MM | DD | BY×Time:

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How to fill out authorization for verbal release

01

Obtain the proper authorization form from the organization or entity that requires it.

02

Fill out the form completely with accurate information such as your full name, date of birth, the name of the person who is authorized to release the information, and the specific information that can be released.

03

Sign and date the form to verify your consent for the verbal release of information.

04

Make a copy of the completed form for your records before submitting it to the appropriate party.

Who needs authorization for verbal release?

01

Anyone who wants to authorize someone else to release information on their behalf needs authorization for verbal release. This could include patients authorizing healthcare providers to discuss medical records with a designated family member, or clients authorizing financial institutions to share account information with a trusted advisor.

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What is authorization for verbal release?

Authorization for verbal release is a formal document granting permission to share verbal information with specified individuals or entities.

Who is required to file authorization for verbal release?

Individuals or entities seeking to disclose verbal information may be required to file authorization for verbal release.

How to fill out authorization for verbal release?

Authorization for verbal release can be filled out by providing the necessary information about the disclosing party, recipient, purpose of disclosure, and any limitations or restrictions.

What is the purpose of authorization for verbal release?

The purpose of authorization for verbal release is to ensure that verbal information is shared only with authorized parties in a secure and controlled manner.

What information must be reported on authorization for verbal release?

Information such as the names of the disclosing and recipient parties, the purpose of disclosure, any restrictions or limitations, and the expiration date of the authorization must be reported on the form.

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