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AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATIONPatient Name:___Medical Record No.___Address: ___I authorize [COVERED ENTITY] to use or disclose my health information as described below.1.
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How to fill out 471-may a covered entity

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How to fill out 471-may a covered entity

01
Obtain the 471-MAY form from the appropriate regulatory agency's website.
02
Fill in the covered entity's name and contact information at the top of the form.
03
Indicate the type of entity you are by selecting the appropriate checkbox.
04
Provide details about the services offered by your entity in the required section.
05
Enter the number of individuals served and any relevant demographic information.
06
Attach any necessary supporting documentation as outlined in the instructions.
07
Review the form thoroughly for completeness and accuracy.
08
Submit the form by the specified deadline, either electronically or by mail as instructed.

Who needs 471-may a covered entity?

01
Healthcare providers, including hospitals and outpatient clinics, that qualify as covered entities.
02
Organizations involved in research that requires approval for certain healthcare activities.
03
Entities seeking federal support or funding for healthcare-related programs.
04
State and local health departments that manage public health programs.

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471-may a covered entity is a specific form required by certain regulatory authorities to report information regarding covered entities that provide health care services.
Covered entities involved in health care, such as hospitals, clinics, and insurance providers, are required to file the 471-may a covered entity form.
To fill out the 471-may a covered entity form, entities must provide their legal name, address, nature of services, and specific data as directed within the form's sections.
The purpose of 471-may a covered entity is to collect and verify information about the operations and compliance of health care entities.
The form requires reporting of the entity's identifying information, financial data, and compliance status with applicable health care regulations.
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