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  • If This Authorization Is Not Signed And Dated, It Will Be Returned

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L Revenue Service IF THIS AUTHORIZATION IS NOT SIGNED AND DATED, IT WILL BE RETURNED. Telephone ( ) Function Date 1 Taxpayer information. Social security number(s) / / Employer identification number Daytime telephone number Taxpayer name(s) and address (please type or print) Plan number (if applicable) ( ) 2 Appointee. Name and address (please type or print) CAF No. ) Telephone No. ( ( ) Fax No. Check if new: Address Telephone No. 3 Tax matters. The appointee is authorized to.

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The core elements of a valid authorization include: 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.

The patient may enter a date range of information to be shared. If no expiration date is specified, this authorization is good for 12 months from the date signed in Section IX.

A verbal authorization on file is good for 14 days. The CSR may advise the beneficiary and the caller that if the beneficiary wants the caller to receive information for more than 14 days, the beneficiary should send in a written authorization.

Must an authorization always have an expiration date? In order to be HIPAA compliant, YES. The privacy rule requires that authorization has either an expiration date or an expiration event.

An authorization must contain an expiration date. After signing an authorization, the patient can decide to revoke it. You must obtain patient agreement to use/disclose PHI for public health activities related to disease prevention.

The date that a valid authorization is signed has no effect on the validity of the authorization. An authorization is considered invalid when the expiration date has passed or the expiration event is known by the covered entity to have occurred.

To be valid, the authorization must contain certain “core elements” set forth in HIPAA; if it does not, the authorization is invalid and you will violate HIPAA by making the disclosure even though the patient signed the form—because there is no “good faith” compliance. (45 C.F.R. § 164.508(b)).

The patient may enter a date range of information to be shared. If no expiration date is specified, this authorization is good for 12 months from the date signed in Section IX.

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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