FPM HIPAA COMPLIANT AUTHORIZATION FOR THE …
HIPAA COMPLIANT AUTHORIZATION FOR THE release OF PATIENT information PURSUANT TO 45 CFR TO: ________________________________________ ______________________________ Name of Healthcare Provider/Physician/Facility/Medicare Contractor ________________________________________ ______________________________ Street Address ________________________________________ ______________________________ City, State and Zip Code Phone Number: _________________________ Fax Number: _________________ RE: Patient Name: ________________________________________ __________________ Date of Birth: _________________ Social Security Number: _____________________ I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim.
HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508 TO: _____ Name of Healthcare Provider/Physician/Facility/Medicare ...
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