INSTRUCTIONS FOR COMPLETING AUTHORIZATION ... - Home UW Health 2025

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
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This form can be used when referring a patient to any of the UW Health pediatric or adult specialty clinics in northern Illinois. Please fax the form to (608) 267-8148. Once the fax is received, it will be reviewed and processed.
If the patient does not provide a written authorization of release of PHI, the doctor may not release the PHI even if the patient gives verbal permission. An authorization of release of PHI gives a physician the legal authority to release the PHI.
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.
Ways to make an appointment Current patientsSchedule through MyChart. If you are a current UW Health patient, you can schedule an in-person or video appointment with your provider. Current patientsCall for an appointment. Patients can call their clinic to schedule an appointment. Cancer patientsRequest a second opinion.
A HIPAA-compliant HIPAA release form must, at the very least, contain the following information: 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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Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.
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.
If you need a copy of a medical record from UW Medical Center, Harborview Medical Center, or the Neighborhood Clinics, please visit their website or contact Release of Information directly at 206-744-9000 or fax 206-744-9997.

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