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  • Where To Send Planned Parenthood Authorisation For Release Form

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PLANNED PARENTHOOD) Corporate Office: 4600 Gulf Freeway, TX 77023 713-522-6240 AUTHORIZATION FORM FOR RELEASE OF HEALTH INFORMATION PATIENT NAME: LAST FIRST MI MAIDEN OR OTHER NAME WHAT OTHER NAMES.

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Elements of a release form Patient information. Naturally, the release should require the patient's information so it's clear who the form refers to. ... Receiving party's information. ... Information to be shared. ... Purpose of the release. ... Expiration of authorization. ... Disclaimers. ... Date and signature.

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 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.

A HIPAA authorization form, also known as a HIPAA release form, is a document that individual signs for their health provider before the entity may use or disclose their protected health information (PHI).

If you choose to use insurance, and there is a problem with the insurance or payment, we may send you mail in an envelope that says PLANNED PARENTHOOD. We need a contact person in case of an emergency while you are in our health center. (The person MUST be 19 years of age or older.)

Patient information. Whose health records do you want? ... Clinic, hospital, care provider. Who has the information you want? ... Date of Services. Who has the information you want? ... Information to be released. ... Receiving party or destination of records. ... Purpose of release. ... Expiration date or duration of consent. ... Release instructions.

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 ...

This form is used to release your protected health information as required by federal and state privacy laws.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232