Home
Forms Library
AUTHORIZATION TO RELEASE CLAIM HISTORY

AUTHORIZATION TO RELEASE CLAIM HISTORY 2025

AUTHORIZATION TO RELEASE CLAIM HISTORY Preview on Page 1

See details

4.1 out of 5

50 votes

The document is an 'Authorization to Release Claim History and Coverage Verification Form' that allows providers to request their loss history report from Coverys. It outlines the necessary information required for the request, associated fees, and instructions for submission. Current insureds receive one free report annually, while others incur a fee. The form must be signed and dated by the provider, and it emphasizes the importance of verifying the accuracy of the information provided.

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out AUTHORIZATION TO RELEASE CLAIM HISTORY with our platform

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open the AUTHORIZATION TO RELEASE CLAIM HISTORY in the editor.
Begin by entering your name as the provider in the 'Type or Print Name of Provider' field. Ensure accuracy for prompt processing.
Fill in the 'Name of Group or Organization' and your 'Current Mailing Address' to ensure that correspondence is directed correctly.
Provide your 'Phone Number', 'Medical License Number', and the last four digits of your Social Security Number for identification purposes.
Input your 'Policy #' and 'Account #' if known, along with your NPI # to facilitate accurate reporting.
Specify where you want the reports sent by filling out the 'Company/Organization Name' and their corresponding mailing address.
Sign and date the form in the designated areas. Remember, stamped signatures are not accepted.

Start using our platform today to complete your AUTHORIZATION TO RELEASE CLAIM HISTORY easily and for free!

See more AUTHORIZATION TO RELEASE CLAIM HISTORY versions

We've got more versions of the AUTHORIZATION TO RELEASE CLAIM HISTORY form. Select the right AUTHORIZATION TO RELEASE CLAIM HISTORY version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2020	4.5 Satisfied (35 Votes)
2018	4.9 Satisfied (39 Votes)
2014	4.1 Satisfied (50 Votes)
2012	4.8 Satisfied (51 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

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 VA form 21 674 used for?

Use VA Form 21-0845 to authorize VA to share your personal information with a non-VA (third-party) individual or organization.

What is the VA form 21 4142a general release for medical provider information?

Use VA Form 21-4142a to give us permission to get medical provider information from a non-VA source like a private doctor or hospital. This will allow us to gather information like the name and address of a facility and your medical treatment dates.

What information should be on the authorization to release information?

Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

How to write an authorization to release medical records?

I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law.

What is the VA form authorization to release medical records?

If you change your mind and want to share your health information, youll need to submit VA Form 10-10163 (Request for and Permission to Participate in Sharing Protected Health Information). Mail the signed, completed form to our ROI office. You can also bring it with you or ask for this form when you visit us.

What form do I use to release medical records to the VA?

To allow sharing after opting out If you change your mind and want to share your health information, youll need to submit VA Form 10-10163 (Request for and Permission to Participate in Sharing Protected Health Information).

Which scenario requires an authorization to release medical records?

The scenarios in which a valid HIPAA authorization form is required are listed in 164.508 and include: Prior to disclosing PHI for marketing purposes. Prior to disclosing PHI for fundraising purposes. Prior to disclosing PHI to a research organization. Prior to disclosing PHI in psychotherapy notes.

AUTHORIZATION TO RELEASE CLAIM HISTORY 2025

Here's how it works

How to use or fill out AUTHORIZATION TO RELEASE CLAIM HISTORY with our platform

See more AUTHORIZATION TO RELEASE CLAIM HISTORY versions

Complete this form in 5 minutes or less

Got questions?

What is VA form 21 674 used for?

What is the VA form 21 4142a general release for medical provider information?

What information should be on the authorization to release information?

How to write an authorization to release medical records?

What is the VA form authorization to release medical records?

Complete this form in 5 minutes or less

People also ask

What form do I use to release medical records to the VA?

Which scenario requires an authorization to release medical records?

Related links

Try more PDF tools

AUTHORIZATION TO RELEASE CLAIM HISTORY 2025

Here's how it works

How to use or fill out AUTHORIZATION TO RELEASE CLAIM HISTORY with our platform

See more AUTHORIZATION TO RELEASE CLAIM HISTORY versions

Complete this form in 5 minutes or less

Got questions?

What is VA form 21 674 used for?

What is the VA form 21 4142a general release for medical provider information?

What information should be on the authorization to release information?

How to write an authorization to release medical records?

What is the VA form authorization to release medical records?

Related Searches

Related forms

Complete this form in 5 minutes or less

People also ask

What form do I use to release medical records to the VA?

Which scenario requires an authorization to release medical records?

Related links

Try more PDF tools