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How to fill out the 19017-Authorization For Release Disclosure Of PHI.doc online
Completing the 19017-Authorization For Release Disclosure Of PHI document online is an important step in managing your protected health information. This guide provides clear, step-by-step instructions to help you navigate the process smoothly.
Follow the steps to complete the authorization form effectively.
- Click the ‘Get Form’ button to access the document and open it in your preferred online editor.
- Begin by filling out the section that includes your request for the release of records. Indicate who you are authorizing, such as the Gwinnett Hospital System or another specified individual.
- Specify the reason for the records release by selecting one of the checkboxes, such as 'Continued Treatment,' 'Insurance,' or 'Other,' and fill in any applicable details.
- Enter your personal information, including your full name, date of birth, social security number, and current address.
- Indicate the medical record number if applicable and provide your phone number for home and work.
- Select from the list of facilities or departments that you authorize to release your information by marking the corresponding checkboxes.
- Provide the name, organization, and address of the recipient to whom the information will be sent. Choose the preferred method for delivery (by mail, fax, or in person).
- Specify the types of information you wish to be released by checking the appropriate items from the list provided.
- If you have additional information that needs to be specified, include that in the designated section.
- Review the consent and understanding section to ensure you are fully informed of your rights regarding the release of your information.
- Sign the document to authorize the release, date it, and indicate if you are signing as a legal representative.
- Once all sections have been completed, ensure you save your changes, then download, print, or share the form as needed.
Complete and submit your authorization forms online to manage your health information effectively.
When is HIPAA Authorization Required? 45 CFR §164.508 details the uses and disclosures of PHI that require an authorization to be obtained from a patient/plan member before information can be shared or used. HIPAA authorization is required for: Use or disclosure of PHI otherwise not permitted by the HIPAA Privacy Rule.
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