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or email to tjones105@radford.edu
AUTHORIZATION FOR RELEASE OF INFORMATION
FROM STUDENT HEALTH RECORD
Name (print)Date of BirthAddress
CityStatePhone NumberEmailProgramZip
(must
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How to fill out patient authorization to release
How to fill out patient authorization to release
01
Obtain the patient authorization to release form from the healthcare provider.
02
Fill out the patient's personal information such as full name, date of birth, and address.
03
Specify the information to be released and to whom it will be released to.
04
Sign and date the form, ensuring it is done by the patient or their legal guardian.
05
Submit the completed form to the healthcare provider or organization as required.
Who needs patient authorization to release?
01
Healthcare providers
02
Insurance companies
03
Legal representatives
04
Third-party organizations requesting medical records
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What is patient authorization to release?
Patient authorization to release is a legal document that allows healthcare providers to disclose a patient's medical information to a third party.
Who is required to file patient authorization to release?
The patient or their legal guardian is required to file patient authorization to release.
How to fill out patient authorization to release?
Patient authorization to release can be filled out by providing the patient's personal information, the information of the person or entity to whom the medical information will be released, and signing and dating the form.
What is the purpose of patient authorization to release?
The purpose of patient authorization to release is to protect the privacy and confidentiality of a patient's medical information.
What information must be reported on patient authorization to release?
Patient authorization to release must include the patient's name, date of birth, medical record number, the specific information to be released, the purpose of the release, and the expiration date of the authorization.
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