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Pa louse Medical, P.S. pH. (509) 3322517 Fax (509) 3349247Pullman Reader 825 SE Bishop Blvd., Suite 200 Pullman, WA 99163www.palousemedical.authorization TO REQUEST/DISCLOSE PROTECTED HEALTH INFORMATION PATIENT

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How to fill out authorization-to-request-or-disclose-personal-health

01

Fill out the patient's name, date of birth, and contact information.

02

Specify the type of information being requested or disclosed.

03

Indicate the purpose of the request or disclosure.

04

Include the name of the healthcare provider or facility releasing the information.

05

Sign and date the authorization form.

Who needs authorization-to-request-or-disclose-personal-health?

01

Individuals who need to request or disclose personal health information on behalf of themselves or another person.

02

Healthcare providers who need to share a patient's medical records with another provider or entity.

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What is authorization-to-request-or-disclose-personal-health?

Authorization-to-request-or-disclose-personal-health is a form that allows an individual to give permission for their personal health information to be shared with a specific person or organization.

Who is required to file authorization-to-request-or-disclose-personal-health?

Any individual who wants their personal health information to be disclosed to a third party is required to file an authorization-to-request-or-disclose-personal-health form.

How to fill out authorization-to-request-or-disclose-personal-health?

The form must be completed with the individual's personal information, the information of the person or organization requesting the health information, and a detailed description of the information being requested or disclosed.

What is the purpose of authorization-to-request-or-disclose-personal-health?

The purpose of the form is to protect the privacy of an individual's personal health information by ensuring that it is only shared with authorized parties.

What information must be reported on authorization-to-request-or-disclose-personal-health?

The form must include the individual's name, date of birth, contact information, the name of the person or organization requesting the information, and a description of the information being requested or disclosed.

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