Get AK ANMC Checklist For Release Of Protected Health Information/Authorization Forms

Authorizations should include the patient's name, address, and date of birth. The patient should sign authorizations, unless he/she is not a legal, competent adult; parents or guardians should sign authorizations in that case. Only the information specifically requested should be released.

The name of the person or organization who is authorized to receive the PHI. A description of the purpose for the use or disclosure. An expiration date for the authorization. The signature of the person making the authorization.

Authorization. A covered entity must obtain the individual's written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service. The purpose of the requested use and disclosure.

A covered entity is permitted, but not required, to use and disclose protected health information, without an individual's authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3) ...

Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.

An authorization must specify a number of elements, including a description of the protected health information to be used and disclosed, the person authorized to make the use or disclosure, the person to whom the covered entity may make the disclosure, an expiration date, and, in some cases, the purpose for which the ...

A meaningful description of the information to be disclosed. The name of the individual or the name of the person authorized to make the requested disclosure. The name or other identification of the recipient of the information.