Protected Health Information (PHI) Release Example Form

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A form that allows patients to authorize the release of their Protected Health Information (PHI) to a third party, such as an insurance company or another healthcare provider. It typically includes fields for:

• Patient's name and date of birth
• Medical record number or other identifier
• Name and address of the third party receiving the PHI
• Type and scope of information being released
• Date and time of signature

Implementing a Protected Health Information (PHI) Release Example Form can benefit your organization in several ways:

• Ensures compliance with HIPAA regulations
• Reduces liability risks associated with unauthorized disclosure of PHI
• Improves transparency and accountability in data sharing processes
• Enhances patient trust and confidence by providing clear information about their rights and responsibilities related to PHI
• Facilitates efficient and accurate management of patient requests for access or disclosure of their health records

Patient's Demographic Information Authorization Type and Purpose Authorized Individual or Organization Authorized Representative Details Restrictions on Use and Disclosure Effective Date and Expiration Date Signature Block for Patient/Authorized Representative Certification by Authorized Official