Chcr 004 form 2025

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The document is a Patient Authorization form that allows a patient to authorize the disclosure of their Protected Health Information (PHI) from a Centura facility to specified organizations, agencies, or individuals. It includes sections for patient details, purpose of disclosure, types of information to be released, and acknowledges the patient's rights regarding the authorization. The form emphasizes that signing is voluntary and outlines conditions under which the authorization expires.

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Versions	Form popularity	Fillable & printable
2012	5 Satisfied (55 Votes)
2012	4 Satisfied (48 Votes)
2011	4.3 Satisfied (194 Votes)

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