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AUTHORIZATION TO RELEASE BEHAVIORAL HEALTH INFORMATION INSTRUCTIONS (for internal use) 1. PATIENT INFORMATION Patient Name: Street Address: City, State, Zip: Maiden/Other Name(s): Record copy request
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How to fill out authorization-for-release-of-phi
How to fill out authorization-for-release-of-phi
01
Obtain the authorization-for-release-of-phi form from the healthcare provider or facility.
02
Fill in the requested personal information such as full name, date of birth, and contact information.
03
Specify the purpose of the disclosure and the exact information to be released.
04
Sign and date the form, indicating your consent for the release of protected health information.
05
Make a copy of the completed form for your records before submitting it to the healthcare provider or facility.
Who needs authorization-for-release-of-phi?
01
Anyone who wishes to authorize the release of their protected health information (PHI) to a third party.
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What is authorization-for-release-of-phi?
Authorization for release of protected health information (PHI) is a form that allows individuals to give permission for their PHI to be disclosed to a specific person or organization.
Who is required to file authorization-for-release-of-phi?
Any individual who wishes to authorize the release of their protected health information (PHI) is required to file an authorization-for-release-of-phi form.
How to fill out authorization-for-release-of-phi?
To fill out an authorization-for-release-of-phi form, you will need to provide your personal information, specify the recipient of the information, describe the type of information being disclosed, and sign and date the form.
What is the purpose of authorization-for-release-of-phi?
The purpose of an authorization-for-release-of-phi form is to ensure that individuals have control over who can access their protected health information (PHI) and for what purpose.
What information must be reported on authorization-for-release-of-phi?
The authorization-for-release-of-phi form must include the individual's personal information, the specific information being released, the recipient of the information, the purpose of the disclosure, and any expiration date for the authorization.
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