Authorization to release financial information - Sites UCI 2025

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Elements: A description of the PHI. The name of the person making the authorization. The name of the person or organization who is authorized to receive the PHI. A description of the purpose for the use or disclosure. An expiration date for the authorization. The signature of the person making the authorization.
Financial Holds may be placed on your account for any of the following reasons: Past Due Balance on your ZOT Account. Returned Items. Payments returned unpaid by the bank. Transfer Unpaid Debt to Collection.
Authorization for release of information means the form prescribed by the agency for the purpose of authorizing the release of a confidential record, signed and dated by the person empowered to release the 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.
What Information Should be Detailed on a HIPAA Release Form? A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.

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Specific and meaningful information, including a description, of the information that will be used or disclosed. The name (or other specific identification) of the person or class of persons authorized to make the requested use or disclosure.
To request an appeal, please call our office at (949) 824-8262 starting in August.
The form must have a valid signature, date, and purpose of the release of the request. If the patients information is incorrect or incomplete, it may lead to the release of the wrong medical records. Healthcare providers must ensure that all patient information on the form is accurate.

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