Home
Forms Library
PATIENT FREEDOM OF INFORMATION ACT PROVIDER PROFILE REPORT FORM

PATIENT FREEDOM OF INFORMATION ACT PROVIDER PROFILE REPORT FORM 2025

See details

4 out of 5

28 votes

The document is the 'Patient Freedom of Information Act Provider Profile Report Form' required by Idaho Code §54-4603 for healthcare professionals seeking licensure or registration. It mandates applicants and currently licensed providers, including chiropractors, dentists, and nurses, to provide detailed personal and professional information such as education, specialty certifications, practice history, admitting hospitals, Medicaid/Medicare participation, criminal history, disciplinary actions, malpractice history, and professional liability insurance. The form emphasizes the importance of truthful disclosure and outlines potential penalties for non-compliance.

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 PATIENT FREEDOM OF INFORMATION ACT PROVIDER PROFILE REPORT FORM

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open it in the editor.
Begin by entering your licensee information, including your profession and license number, name, business address, and email address for board use only.
In Section A, provide details about your education. List the names and addresses of medical or professional schools attended along with graduation dates.
For Section B, enter any specialty certifications recognized by the board.
In Section C, if applicable, describe any special positions held at medical/professional schools over the last ten years.
Section D requires you to detail your practice history for the past ten years. Include facility names, addresses, types of practice, and relevant dates.
Continue filling out Sections E through N with information regarding admitting hospitals, Medicaid/Medicare participation, criminal history, disciplinary actions, malpractice history, and ownership interests as required.
Finally, review all entries for accuracy before signing at the bottom of the form to affirm that the information is true and correct.

Start using our platform today to easily complete your PATIENT FREEDOM OF INFORMATION ACT PROVIDER PROFILE REPORT FORM online for free!

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 a patient release of information form?

A medical records release form is a document that authorizes the release of patient health information from one healthcare provider to a requestor.

Which documents patient information sent to authorized requestors?

Thus, individuals have a right to a broad array of health information about themselves maintained by or for covered entities, including: medical records; billing and payment records; insurance information; clinical laboratory test results; medical images, such as X-rays; wellness and disease management program files;

What is a release of information form?

A Release of Information (ROI) is a document that allows a client to choose what information is released from their medical record. It also allows the client to choose who receives the information, how long it can be released, and under what guidelines.

What is the meaning of information release?

Release of information refers to the disclosure or sharing of confidential, personal, or business-related data with authorized individuals or entities. This process is often regulated by privacy laws, contractual agreements, or corporate policies to ensure proper handling and protection of sensitive information.

What is a medical record release form?

A medical record release form is a legal document that allows the patient access to their medical record. This form is used by medical organizations to track the medical history of patients and ensure that all information is accurate.

What is the release of patient information?

The release of information is a structured process for disclosing patient health data to authorized individuals or organizations. Its goal is to ensure that the right person receives the right medical information at the right time.

PATIENT FREEDOM OF INFORMATION ACT PROVIDER PROFILE REPORT FORM 2025

Here's how it works