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AUTHORIZATION FOR USE/DISCLOSURE/EXCHANGE OF PROTECTED HEALTH INFORMATION DB HDS/Western State Hospital, P.O. Box 2500, Staunton, VA 244022500Telephone Number : (540) 332___Fax Number: (540) 332___

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How to fill out dbhds authorization for usedisclosure

01

Gather all necessary information like name, address, and contact details of the person authorizing the disclosure

02

Fill out the purpose of the disclosure and specify the information to be disclosed

03

Include the name of the individual or organization authorized to make the disclosure

04

Sign and date the form

Who needs dbhds authorization for usedisclosure?

01

Anyone who needs to disclose or share information governed by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) regulations

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What is dbhds authorization for usedisclosure?

Dbhds authorization for usedisclosure is a form that allows individuals to authorize the disclosure of their personal information.

Who is required to file dbhds authorization for usedisclosure?

Individuals who wish to authorize the disclosure of their personal information are required to file dbhds authorization for usedisclosure.

How to fill out dbhds authorization for usedisclosure?

To fill out dbhds authorization for usedisclosure, individuals must provide their personal information and specify who is authorized to receive the disclosed information.

What is the purpose of dbhds authorization for usedisclosure?

The purpose of dbhds authorization for usedisclosure is to ensure that individuals have control over who can access their personal information.

What information must be reported on dbhds authorization for usedisclosure?

On dbhds authorization for usedisclosure, individuals must report their name, contact information, and the information they wish to disclose.

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