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Community Health Plan of Washington Authorization to Disclose Protected Health Information Use this form if you want Community Health Plan of Washington (CHEW) to share your protected health information

How to fill out authorization-to-disclose-phi-form

How to fill out authorization-to-disclose-phi-form

1. Obtain the authorization-to-disclose-phi-form from the healthcare provider or facility.
2. Read through the form carefully to understand the information being disclosed and the purpose of the disclosure.
3. Fill in your personal information such as name, date of birth, address, and contact information.
4. Specify the recipient(s) of the disclosed information by providing their names, addresses, and contact information.
5. Indicate the type of information being disclosed and specify the purpose of the disclosure.
6. Sign and date the form to certify your authorization for the disclosure of PHI.
7. Submit the completed form to the healthcare provider or facility as directed.

Who needs authorization-to-disclose-phi-form?

1. Individuals who wish to authorize the disclosure of their Protected Health Information (PHI) to a specific recipient or recipients.

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What is authorization-to-disclose-phi-form?

Authorization-to-disclose-phi-form is a legal document that allows an individual or organization to release protected health information (PHI) to a specified third party.

Who is required to file authorization-to-disclose-phi-form?

Any entity or individual that needs to disclose PHI to a third party is required to file the authorization-to-disclose-phi-form.

How to fill out authorization-to-disclose-phi-form?

To fill out the authorization-to-disclose-phi-form, one must provide information about the individual whose PHI is being disclosed, the recipient of the information, the purpose of the disclosure, and any limitations on the disclosure.

What is the purpose of authorization-to-disclose-phi-form?

The purpose of authorization-to-disclose-phi-form is to ensure that PHI is only disclosed in accordance with the individual's wishes and in compliance with relevant privacy laws.

What information must be reported on authorization-to-disclose-phi-form?

The authorization-to-disclose-phi-form must include details such as the type of information being disclosed, the reason for the disclosure, the expiration date of the authorization, and any restrictions on the disclosure.