Get University Of Utah Health Patient Authorization For Disclosure Of Protected Health Information 2006
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How to fill out the University of Utah Health Patient Authorization for Disclosure of Protected Health Information online
Filling out the University of Utah Health Patient Authorization for Disclosure of Protected Health Information online is a straightforward process. This guide will provide comprehensive, step-by-step instructions to help you accurately complete the form and ensure your protected health information is disclosed as intended.
Follow the steps to effectively complete your authorization form.
- Press the ‘Get Form’ button to access the authorization form and open it in your preferred editing tool.
- Provide your personal information in the designated fields. Fill in your name, medical record number, date of birth, phone number, and address. If you choose to provide your social security number, note that it is voluntary but may expedite the identification of your medical records.
- Indicate the approximate dates of treatment that you are authorizing for disclosure.
- Select the health care provider or facility authorized to disclose your patient information. Check all that apply, including options like University Hospital, Hannah Cancer Hospital, or any community or outpatient clinics as relevant.
- Identify the person or organization that you authorize to receive your patient information. Fill in their name, relationship to you, address, and phone number. You can add multiple names if necessary.
- Specify the information you wish to disclose by circling your selection(s) from the provided options such as treatment plans, psychological evaluations, and other relevant records.
- State the purpose for the disclosure of your patient records, checking the box if it is for personal use.
- Acknowledge that the disclosure may include substance abuse treatment program information if applicable, and understand the implications surrounding privacy and potential re-disclosure.
- Confirm that signing this authorization is not a condition for treatment and how you may revoke the authorization later if needed.
- Indicate the expiration of your authorization. Choose from options like one year from the signing date or a one-time disclosure.
- Sign and date the form as the patient or a designated representative. If applicable, provide additional necessary details regarding the representative's authority.
- After completing the form, make sure to save your changes. You may opt to download, print, or share the authorization form as needed.
Take the next step to manage your health information effectively by filling out the authorization form online.
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Certain types of health information require a patient's authorization before they can be shared. This typically includes sensitive data such as mental health records, substance abuse treatment records, and HIV status. At University of Utah Health, we emphasize the importance of patient consent through our Patient Authorization for Disclosure of Protected Health Information.
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