Release health information
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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
www.ucsfhealth.orgto release health information to: (Name of person or facility to receive health information and full address) Street address City State Zip Code Check this box to authorize exchange between the persons/organizations listed above. The purpose of this release is for (check one or more):
Authorization for Release of Health Information ...
www.health.ny.gov* This Authorization for Release of Health Information and Confidential HIVRelated Information form is HIPAA compliant. If releasing only nonHIV related health information, you may use this form or another HIPAAcompliant general health release form. DOH2557 (2/11) Page 1 of 3
Authorization to Release Protected Health Information
hospitals.jefferson.eduAuthorization to Release Protected Health Information Form 1. Please complete all sections of the Authorization to Release Protected Health Information Form. 2. The patient or legally authorized representative must sign and date the form. Jefferson may require proof of representation if the form is signed by a personal representative.
Authorization Release Obtain Exchange Patient Health ...
www.seattlechildrens.orgInstructions for completing the Authorization to Release/Obtain/Exchange Patient Health Information form. Purpose: To request that Seattle Children’s Hospital provides health information to a recipient outside of Children’s, requests that outside information be sent to our organization, or to exchange verbal information about your child.
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH …
med.nyu.eduInclude information relating to (initial beside each applicable category): Alcohol or Drug Treatment. Mental Health Treatment Genetic Testing Information Psychotherapy Notes (If yes, please complete the additional authorization form for this purpose) HIV-Related information (If yes, please complete an official NYSDOH HIV release form)
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH …
www.dhcs.ca.govrelease the following health information: To: (Name and title or facility name to receive health information) (Street address, city, state, ZIP code) (Telephone number) (Fax number) For the following purposes: This authorization is in effect until (date or event), when it expires.
Authorization for Release of Protected Health Information
www.fvfiles.comDirections for Completing the Authorization for Release of Protected Health Information Form Fill out the entire form neatly. Please print. Please note that blank items on this form may cause major delays in processing your request. Complete this form as fully as possible. Allow a minimum of 10 business days for processing.
Allina Health Authorization to Release and Disclose ...
www.allinahealth.orgAllina Health cannot prevent redisclosure of your information by the person or organization who receives your records under this authorization, and that information may not be covered by state and federal privacy protectionsafter it is released. By …