Get the up-to-date Request to Access Protected Health Information PHI - Concentra 2025 now

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The document is a HIPAA release form that authorizes Concentra to use and disclose a patient's protected health information (PHI). It includes sections for patient identification, purpose of disclosure, types of records to be disclosed, and confirmation of the recipient's details. The form also addresses sensitive information related to communicable diseases and mental health, outlines the patient's rights regarding revocation of authorization, and specifies the expiration of the authorization. Additionally, it provides contact information for HIPAA-related inquiries.

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What is an example of a HIPAA authorization?

I hereby authorize use or disclosure of protected health information about me as described below. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.

What is required for releasing protected health information?

A covered entity must obtain an authorization to use or disclose protected health information for marketing, except for face-to-face marketing communications between a covered entity and an individual, and for a covered entitys provision of promotional gifts of nominal value.

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.

Who has permission to access a patients personal health information?

One of your rights as a patient is the ability to access your medical record. You can also give other people, like providers, family members, and insurance companies, permission to see your records.

How to fill out authorization for release of protected health information form?

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.

When can you disclose PHI protected health information without authorization?

A covered entity is permitted, but not required, to use and disclose protected health information, without an individuals authorization, for the following purposes or situations: (1) To the Individual (unless required for access or accounting of disclosures); (2) Treatment, Payment, and Health Care Operations; (3)

How to fill out an authorization form?

A valid authorization must be written in plain language and contain the following elements: A description of the information to be used or disclosed. The identification of the person authorized to make the requested use or disclosure. The name of the person to whom the entity may make the requested use or disclosure.

What is a concentra authorization form?

Before employees can use Concentra Telemed, their employer must submit a treatment authorization on their behalf. This online authorization grants Concentra permission to treat employees for workers compensation injuries or illnesses using our telemedicine platform.

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