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PANEL 16 Form Approved OMB No. 09350118 Exp. Date 01/31/2013 AUTHORIZATION TO OBTAIN INFORMATION FROM MEDICAL AND BILLING RECORDS MEDICAL EXPENDITURE PANEL SURVEY U.S. DEPARTMENT OF HEALTH AND HUMAN

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How to fill out authorization to obtain information

01

Start by addressing the authorization form to the appropriate party such as a healthcare provider or institution.

02

Clearly state the purpose for which the information is being requested.

03

Include the name of the individual whose information is being requested.

04

Specify the type of information being requested.

05

Provide any relevant dates or time periods for which the information is needed.

06

Have the individual whose information is being requested sign and date the authorization form.

07

If applicable, include any additional required information or documentation that may be needed.

Who needs authorization to obtain information?

01

Anyone who wishes to obtain specific information about another individual that is protected by privacy laws and regulations, such as medical records or financial information, will need authorization to obtain that information.

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What is authorization to obtain information?

Authorization to obtain information is a legal document that allows a person or organization to access specific information.

Who is required to file authorization to obtain information?

Any individual or organization seeking to access specific information is required to file an authorization to obtain information.

How to fill out authorization to obtain information?

To fill out an authorization to obtain information, you typically need to provide your personal information, the purpose for which you are seeking the information, and any relevant details about the information being requested.

What is the purpose of authorization to obtain information?

The purpose of authorization to obtain information is to ensure that only authorized individuals or organizations have access to sensitive or confidential information.

What information must be reported on authorization to obtain information?

The information reported on an authorization to obtain information may vary depending on the specifics of the request, but typically includes details about the requester, the purpose for which the information is being requested, and any relevant information about the information being sought.

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