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This document serves as authorization for the UB School of Dental Medicine to discuss or disclose a patient\'s protected health information to a designated Authorized Representative. It includes sections for patient information, types of information to be disclosed, authorized representatives, limitations on disclosure, and revocation of authorization.
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What is authorized representative form?
The authorized representative form is a document used to designate an individual or entity to act on behalf of another person or organization in legal, tax, or administrative matters.
Who is required to file authorized representative form?
Individuals or organizations that wish to appoint an authorized representative to manage their affairs or interact with government agencies, tax authorities, or other entities are required to file this form.
How to fill out authorized representative form?
To fill out an authorized representative form, provide the name and contact information of both the person designating the representative and the representative themselves, along with any relevant identification numbers, a description of the authority granted, and signatures from both parties.
What is the purpose of authorized representative form?
The purpose of the authorized representative form is to legally appoint someone to represent another person in official matters, ensuring that decisions can be made on behalf of the individual or organization when they are unavailable.
What information must be reported on authorized representative form?
The form usually requires the name, address, and identification numbers of both the individual and the representative, details of the authority granted, and any specific limitations on the representation.
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