College Park Family Care Center Authorization for Use/Disclosure of Protected Health Information 2014-2025 free printable template

Medical Record Release Authorization College Park Family Care Center 11755 W 112th St. Suite 203 Overland Park KS 66210 Phone 913-469-4106 Patient NameMaiden NameSS Date of BirthHome PhoneCell/Work AddressCity/State/Zip Email Address A I hereby authorize records FROM B To be released TO Name City/State/Zip Phone Fax Date Rangeto C For the purpose of Litigation Disability/SSI Physician Office Notes Cardiology/EKG Reports Insurance Work Comp Immunizations Lab/Path Reports Self/Personal Copy...

How to fill out College Park Family Care Center Authorization

How to fill out College Park Family Care Center Authorization for Use/Disclosure

1. Obtain the College Park Family Care Center Authorization for Use/Disclosure form, either from the website or at the facility.
2. Fill in the patient's full name, date of birth, and contact information at the top of the form.
3. Specify the purpose of the authorization in the designated section (e.g., for medical treatment, insurance purposes).
4. Identify the specific information to be disclosed, such as medical records, billing records, or treatment history.
5. List the names of the individuals or organizations authorized to receive the information.
6. Indicate the duration for which the authorization is valid, ensuring compliance with legal timeframes.
7. Review the form for accuracy before signing it.
8. Sign and date the authorization at the designated area.
9. Provide any required witnesses or additional signatures as instructed.
10. Submit the completed form to College Park Family Care Center.

Who needs College Park Family Care Center Authorization for Use/Disclosure?

1. Patients seeking treatment at College Park Family Care Center who want their medical information shared with other providers.
2. Family members or guardians of patients who require access to the patient's medical records.
3. Insurance companies that need authorization to process claims related to the patient's care.
4. Researchers or other entities requiring patient information for studies, provided proper protocols are followed.

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What is College Park Family Care Center Authorization for Use/Disclosure?

The College Park Family Care Center Authorization for Use/Disclosure is a legal document that allows the healthcare provider to use or disclose a patient's protected health information for specific purposes.

Who is required to file College Park Family Care Center Authorization for Use/Disclosure?

Patients or their legal representatives are required to file the College Park Family Care Center Authorization for Use/Disclosure when they want to allow the center to share their health information with others.

How to fill out College Park Family Care Center Authorization for Use/Disclosure?

To fill out the College Park Family Care Center Authorization for Use/Disclosure, one must provide personal information, specify what information is being disclosed, to whom it may be disclosed, and sign and date the form.

What is the purpose of College Park Family Care Center Authorization for Use/Disclosure?

The purpose of the College Park Family Care Center Authorization for Use/Disclosure is to ensure that patients' health information is shared legally and with their consent for treatment, payment, or other healthcare operations.

What information must be reported on College Park Family Care Center Authorization for Use/Disclosure?

The information that must be reported includes the patient's name, the specific health information being disclosed, the person or entity to whom the information is being disclosed, the purpose of the disclosure, and the patient's signature.