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Patient Authorization to Disclose Protected Health Information - MRO

Patient Authorization to Disclose Protected Health Information - MRO 2025

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The document is a Patient Authorization form that allows a patient to authorize the disclosure of their Protected Health Information (PHI) from a Centura facility to another organization, agency, or individual. It includes sections for patient details, purpose of disclosure, types of information to be shared, and instructions for delivery. The form emphasizes the voluntary nature of the authorization, the patient's right to revoke it, and outlines potential risks associated with sharing health information.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your name, date of birth, last four digits of your Social Security number, address, and telephone number. This ensures that the authorization is correctly linked to your identity.
Specify the Centura facility that you authorize to disclose your health information. Fill in the name and address of the organization or individual receiving this information.
Indicate the treatment dates and select the type of disclosure authorized. You can choose from options like further medical care, personal use, or legal purposes.
Review the authorization statement carefully. Ensure you understand your rights regarding revocation and privacy before signing and dating the form.

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Versions	Form popularity	Fillable & printable
2012	5 Satisfied (55 Votes)
2012	4 Satisfied (48 Votes)
2011	4.3 Satisfied (194 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is considered protected health information?

Protected health information (PHI) is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment.

What are two required elements of an authorization needed to disclose PHI?

45 CFR 164.508: (i) A description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion. (ii) The name or other specific identification of the person(s), or class of persons, authorized to make the requested use or disclosure.

When must you get authorization from a person to disclose their protected health information in PHI quizlet?

It is required whenever a healthcare provider wants to release the patients PHI to anyone outside the healthcare team or organization. The only exception to the law is if the PHI is shared for treatment, payment, or healthcare operations purposes.

What is an authorization for release of protected patient health information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

What is authorization for disclosure of protected health information?

Authorization. A covered entity must obtain the individuals written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

Is the permission that patients give in order to disclose protected health information?

To respect HIPAA compliance rules, a signed HIPAA release form must be obtained from a patient before their protected health information can be shared with other individuals or organizations, except in the case of routine disclosures for treatment, payment or healthcare operations permitted by the HIPAA Privacy Rule.

What does authorization to disclose protected health information mean?

A HIPAA authorization is a detailed document in which specific uses and disclosures of protected health are explained in full. By signing the authorization, an individual is giving consent to have their health information used or disclosed for the reasons stated on the authorization.

Patient Authorization to Disclose Protected Health Information - MRO 2025

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What is considered protected health information?

What are two required elements of an authorization needed to disclose PHI?

When must you get authorization from a person to disclose their protected health information in PHI quizlet?

What is an authorization for release of protected patient health information?

What is authorization for disclosure of protected health information?

People also ask

Is the permission that patients give in order to disclose protected health information?

What does authorization to disclose protected health information mean?

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Patient Authorization to Disclose Protected Health Information - MRO 2025

Here's how it works

How to use or fill out Patient Authorization to Disclose Protected Health Information - MRO with our platform

See more Patient Authorization to Disclose Protected Health Information - MRO versions

Complete this form in 5 minutes or less

Got questions?

What is considered protected health information?

What are two required elements of an authorization needed to disclose PHI?

When must you get authorization from a person to disclose their protected health information in PHI quizlet?

What is an authorization for release of protected patient health information?

What is authorization for disclosure of protected health information?

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People also ask

Is the permission that patients give in order to disclose protected health information?

What does authorization to disclose protected health information mean?

Related links

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