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[DOC File]Authorization Form - B
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Authorization for Release of Information – Compound Release. ... Results of lab tests/x-rays. Other_____ Other person (s) (provide name and phone number) Financial. Medical. Email communication-Provide email address* ... This authorization will remain in effect until revoked by the patient.
authorization release of information

[DOC File]AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
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I hereby request and authorize UNC Health Care System and its staff to furnish to_____ copies of all records and reports, including x-rays, specimens, reports, charts, findings, and any other protected health information gathered or created in the course of my health care and medical treatment by them during the treatment dates listed above.
release of information authorization form

[DOC File]AUTHORIZATION TO RELEASE INFORMATION
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( ) Labs ( ) X-Rays ( ) All ( ) Office Notes ( ) Procedures Performed I hereby consent to release and disclose the above information obtained in the course of my diagnosis and treatment to the intended parties described above. Signature: Date:
general authorization to release information

[DOC File]Authorization Form - B
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Authorization for Release of Information. ... Voice Mail Results of lab tests/x-rays. Appointment reminders. Other_____ Other person(s) (provide name and phone number) ... This authorization will remain in effect until revoked by the patient.
authorization to release information template

[DOC File]Authorization for Release of Information – Compound Release
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Authorization for Release of Information – Compound Release. Name of Patient _____ Date of Birth _____ _____Dr. Cynthia Bolton D.D.S._____ is authorized to release protected health information about the above named patient in the following manner and to identified persons. ... Results of lab tests/x-rays. Appointment information. Other person ...
authorization to release medical information

[DOC File]AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION FOR CRIMINAL CASES – state COURT. MIM #1151 . IMPRINT . ... (“UNC HCS”) & its staff to furnish copies of all records & reports, including x-rays, specimens, reports, charts, findings, & any other protected health information gathered or created in the course of my health care & medical ...
authorization to release medical records

[DOC File]AUTHORIZATION FOR RELEASE OF INFORMATION
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The above-named attorney(s) and law firm(s) are permitted to receive the information and are hereby appointed as my representative pursuant to La. R.S. 40:1299.96(A)(2)(b) for the limited purpose of obtaining and using any and all information the releasing person(s) or organization(s) may have concerning treatment or services rendered to the ...
blank authorization to release information

[DOCX File]AUTHORIZATION FOR THE RELEASE OF HEALTH …
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Authorization for the Release of Health Information for Research. 2. ... Radiology films (like X-rays or CT scans) Laboratory / diagnostic tests. EKG reports. EEG reports. Psychological testing. Pathology reports. Operative reports (about an operation) Pathology specimen(s) and/or slide(s)
authorization release form

Microsoft Word - HIPAACEUpdates2018
Authorization for Release of Information – Compound Release ... Name of PatientDate of Birth . is authorized to release protected health information about the above-named patient in the following manner and/or to selected persons. ... Results of lab tests/x-rays. Other Other person (s) (provide name and phone number) Financial. Medical Email ...
authorization release of information

[DOC File]AUTHORIZATION FOR RELEASE OF INFORMATION
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The most recent 2 years of pertinent information (chart notes, labs, X-rays and special tests) All medical records. Medical Billing. Specific information (Please specify) Purpose for which disclosure is being made: Processing of an insurance claim. Date of Loss: Page 2 of 2. Claim Number: Patient Authorization:
release of information authorization form

Authorization to release x rays