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  • Ma Fenway Health Authorization For Disclosure Of Protected Health Information 2010

Get Ma Fenway Health Authorization For Disclosure Of Protected Health Information 2010-2025

SOCIAL SECURITY NUMBER DATE OF BIRTH MAIDEN NAME I HEREBY AUTHORIZE: NAME, TITLE ORGANIZATIONS/DEPARTMENT, ADDRESS, PHONE NUMBER To release information from my health record to: NAME, TITLE ORGANIZATIONS/DEPARTMENT, ADDRESS, PHONE NUMBER This authorization covers the following records: q All records q My record for treatment of (please specify diagnosis or symptom.) q My record for treatment received during the following time period.

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A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.

If you have any questions about Fenway Health and would like to speak to a Fenway employee, please call us at 617.267. 0900 during business hours. You can also check out our FAQ page to find out how to get copies of your medical records, what insurance plans we accept, and answers to other questions.

How do I fill out a HIPAA release form? Provide instructions. ... Name the patient and individual authorized to use or disclose their PHI. ... Describe the information. ... Specify recipients. ... Specify the purpose of disclosure. ... Specify the time period. ... Detail their revocation rights. ... Obtain the patient's signature.

By completing the Authorization to Verbally Discuss Protected Health Information Form, it will allow us to talk about your medical care to those you have designated. This includes appointment and scheduling information, lab and test results, treatment information, and billing information.

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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
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