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Authorization to Release Record of Protected Health Information (PHI) VERIFY CURRENT INFORMATION (please print) Date of Request: Member Name:Date of Birth:Care 1st ID#:Phone #:Address:YOUR Requester

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How to fill out authorization to release record

01

Obtain the correct form for authorization to release records.

02

Fill in your personal information such as name, date of birth, and address.

03

Specify the records you are authorizing to be released.

04

Include the name of the person or organization that will be receiving the records.

05

Sign and date the form to authorize the release of the records.

Who needs authorization to release record?

01

Individuals who want to authorize the release of their records to a specific person or organization.

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What is authorization to release record?

Authorization to release record is a document that allows a third party to access an individual's records or information.

Who is required to file authorization to release record?

The individual whose records are being released is required to file the authorization to release record.

How to fill out authorization to release record?

To fill out the authorization to release record, one must include personal information, specify the records to be released, and sign the document.

What is the purpose of authorization to release record?

The purpose of authorization to release record is to protect the privacy rights of individuals by ensuring that their information is only disclosed with their consent.

What information must be reported on authorization to release record?

The information reported on authorization to release record includes the individual's name, the purpose of the release, the specific records to be released, and the duration of the authorization.

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