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Get Wageworks Gen 7003.2 (ww-6949-hipaa-ppt-auth) 2010
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How to fill out the Wageworks GEN 7003.2 (WW-6949-HIPAA-PPT-AUTH) online
Filling out the Wageworks GEN 7003.2 form online is an important step in authorizing the use and disclosure of your protected health information. This guide offers clear, step-by-step instructions to help you complete the form accurately and efficiently.
Follow the steps to complete the form correctly.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- In Section A, enter the participant's name along with their mailing address, city, state, and zip code. Provide a valid telephone number and either the social security number or the participant ID number assigned by WageWorks.
- Move to Section B to specify the protected health information (PHI) that you are authorizing to be used and/or disclosed. Clearly describe the nature of the PHI.
- If applicable, check the box if this authorization is specifically for psychotherapy notes. Remember, this authorization cannot be used for any other type of PHI.
- In the next field, list the entities or persons authorized to use or disclose the specified PHI. Be as specific as possible regarding names or organizational titles.
- Identify the entities or persons authorized to receive the PHI. Clearly state who should have access to the specified information.
- Indicate the purpose of this authorization, ensuring that the reason reflects either a request by the individual or any specified purpose.
- In Section C, set an expiration date for the authorization or describe an event that will cause it to expire.
- Acknowledge the right to revoke the authorization by noting that written notice can be given to WageWorks, Inc. This note clarifies that revoking does not affect actions taken before revocation.
- In Section D, sign and date the form, ensuring that your printed name is clearly included. If a personal representative is signing on behalf of someone else, they must also provide their name, signature, date, and relationship to the individual.
- After completing and signing the form, keep a copy for your records. Submit the form to WageWorks, Inc. at the provided address or via fax.
Complete your Wageworks GEN 7003.2 form online to manage your healthcare information effectively.
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