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Patient Information Release Form - Henry Ford Health System 2025

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The document is a Patient Information Release Form that authorizes the disclosure of a patient's medical records to specified individuals or organizations. It outlines the necessary information to be filled out, including patient details, purpose of disclosure, and specific information requested. The form emphasizes the importance of completing all sections accurately and notes that incomplete forms will not be processed. It also includes terms regarding revocation of authorization, potential re-disclosure of information, and associated fees for processing.

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Versions	Form popularity	Fillable & printable
2021	4.8 Satisfied (111 Votes)
2020	4.4 Satisfied (125 Votes)
2020	4.2 Satisfied (103 Votes)
2018	4.3 Satisfied (97 Votes)
2017	4.3 Satisfied (120 Votes)
2016	4.2 Satisfied (64 Votes)
2014	4 Satisfied (32 Votes)
2010	4 Satisfied (57 Votes)

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What is a patient release form?

A HIPAA release form is a document that when signed allows healthcare providers to share a patients protected health information (PHI) with specified individuals or organizations, ing to the details stipulated in the form.

What is the new name for Henry Ford Health System?

0:00 0:52 Well today Henry Ford Health and Ascension Michigan officially launched their combined operationMoreWell today Henry Ford Health and Ascension Michigan officially launched their combined operation becoming the second largest health care system in the state under the deal announced last year

Who authorizes release of medical information?

The person who authorizes the release of medical information is primarily the patient, as established by HIPAA. Patients have the right to control access to their medical information and can specify who can view it.

Which is the patients authorization to release information required?

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.

Who has permission to access a patients personal health information?

An individuals personal representative (generally, a person with authority under State law to make health care decisions for the individual) also has the right to access PHI about the individual in a designated record set (as well as to direct the covered entity to transmit a copy of the PHI to a designated person or

henry ford medical records release form

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Who must provide release of information?

Whether presenting a settlement offer or releasing medical records to a third party for a case, the claimant is required to sign a release of information as a protective measure against unnecessary medical information being disclosed.

Who is authorized to release patient information?

The Privacy Rule allows those doctors, nurses, hospitals, laboratory technicians, and other health care providers that are covered entities to use or disclose protected health information, such as X-rays, laboratory and pathology reports, diagnoses, and other medical information for treatment purposes without the

Patient Information Release Form - Henry Ford Health System 2025

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