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INS5216A: Have this form completed by the patient or their legal representative authorizing the medical doctor or nurse practitioner to complete the medical certificate for Compassionate Care benefits.
This form is used to release your protected health information as required by federal and state privacy laws. 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.
How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.
Generally, an authorization provides the authority for a doctors release of PHI for specified purposes, which are generally other than treatment, payment, or healthcare operations, or, to disclose protected health information to a third party specified by the individual.
The purpose for this authorization is to determine a physical or mental condition, illness, or disability and the right, if any, to retirement, reinstatement, or other benefits under the Public Employees Retirement Law (PERL) (Government Code sections 20000, et seq.)
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The HIPAA Authorization Form For Family Members can be utilized to authorize the designated person to handle billing and insurance-related matters on behalf of the patient. This includes processing insurance claims, submitting reimbursement requests, and resolving billing or payment issues.

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