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PATIENT DISCLOSURE HIPAA AUTHORIZATION FORM Date:___Patient Name:___I authorize Community Smiles to disclose the patients protected health information (PHI) only in the specific manner, for the named

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How to fill out i authorize community smiles

01

Fill out your full name and address in the 'Personal Information' section.

02

Sign and date the 'Authorization' section.

03

Provide your insurance information if applicable.

04

Make sure all required fields are completed before submitting the form.

Who needs i authorize community smiles?

01

Patients who are receiving dental services from Community Smiles may need to fill out the 'I authorize Community Smiles' form.

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What is i authorize community smiles?

I authorize community smiles is a form that allows individuals to grant permission for community services to share their information for support and assistance.

Who is required to file i authorize community smiles?

Individuals who wish to receive community services and need to share their information with service providers are required to file i authorize community smiles.

How to fill out i authorize community smiles?

To fill out i authorize community smiles, provide your personal information, the details of the service providers, and sign the authorization section to consent to the information sharing.

What is the purpose of i authorize community smiles?

The purpose of i authorize community smiles is to enable individuals to authorize community service providers to access their personal information for the facilitation of support and resources.

What information must be reported on i authorize community smiles?

The information that must be reported includes the individual's name, contact information, the services being requested, and the names of the providers authorized to receive the information.

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