Authorization For Release Of Information

State:
Michigan
Control #:
MI-BM-070-13
Format:
PDF
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Description

A13 Stipulation And Order Compelling Authorizations

How to fill out Authorization For Release Of Information?

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FAQ

An authorization is a detailed document that gives covered entities permission to use protected health information for specified purposes, which are generally other than treatment, payment, or health care operations, or to disclose protected health information to a third party specified by the individual.

Release of information (ROI) is the process of providing access to protected health information (PHI) to an individual or entity authorized to receive or review it.

Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.

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.

You may disclose the PHI as long as you receive a request in writing. The written request must contain: the covered entity's name, the patient's name, the date of the event/time of treatment, and the reason for the request.

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This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL. I would like copies of the items checked below for the treatment dates listed above.Please download, complete and sign the form and send to Health Information Management (HIM). To complete this form for me. For copies of your AMG records, you must complete an authorization form. Please clearly and legibly print all information when completing this form and sign on the last page. Information under the HIPAA (OCA960). These instructions will help you to complete the Authorization for Release of Health Information. Purpose and Laws: This form, when properly completed, permits the release of confidential information about a person receiving services. When is a HIPAA Authorization to Release Medical Information Form Required?

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Authorization For Release Of Information