Hoosierservicesinc.com

Sutter Health Authorization for Use and Disclosure of Health …

WEBAttn: HIM Director Attn: HIM Director Attn: HIM Director Attn: HIM Director Attn: HIM Director Attn: HIM Director PO Box 619091 795 El Camino Real 3687 Mt. Diablo Blvd …

Actived: 8 days ago

URL: https://hoosierservicesinc.com/home/hipaaforms/sutter%20medical%20foundation%20hipaa.pdf

REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL

WEBrequest for and authorization to release medical records or health information. note: additional items of information desired may be listed on the back of this form

Category: Medical Go Health

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED …

WEBST ST 435. Stanford Health Care (SHC) 300 Pasteur Drive Stanford, CA 94305 Phone: 650-723-5721. Page 3 of 6. 151 31. AUTHORIZATION • DISCLOSURE OF HEALTH …

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AUTHORIATION TO DISCLOSE PROTECTED HEALTH …

WEB43530 538498 (07/14) AUTHORIATION TO DISCLOSE PROTECTED HEALTH INORMATION/MEDICAL RECORDS Patient Name (please print): Maiden or Other …

Category: Medical Go Health

Request to Obtain a Copy of or Inspect Your Health Information

WEB100-8700-739SW (Rev. 12/4/13) EXPLANATION: This form authorizes the use or disclosure of protected health information in the manner described below and is …

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Patient Information: I give permission to release the health

WEBPatient Information: I give permission to release the health information of: (One Patient Per Form)

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Authorization for Release of Health Information

WEBAuthorization for Release of Health Information In.tructions: SectioDI 1-7 mUlt be eo.pleted for an requests aDd sigaatures. Please prlDt legibly to black Ink oaly.

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(for internal purposes)

WEBAUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION HEALTH INFORMATION MANAGEMENT DEPARTMENT 35557 NONCH35557 01/15 …

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Authorization to Records

WEBAuthorization to Release Medical Records: PATIENT INFORMATION: Name (print) DOB SSN _____ _____ _____ INFORMATION TO BE RELEASED FROM:

Category: Medical Go Health

AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH …

WEBAUTHORIZATION FOR RELEASE OF MEDICAL RECORDS. 1520 San Pablo St. Suite 1000 Los Angeles, Ca. 90033 Phone: 323 442-5640 Fax: 323 442-5641.

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Release of Information Authorization

WEBRelease of Information Authorization 105559 (10/17) PAGE 1 OF 1 Release of Information Authorization Patient Name: _____ Date of Birth: _____

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COH Duarte COH Antelope Valley COH South Pasadena COH …

WEBPURPOSE: I authorize COH to use/disclose my health or highly confidential information I selected above, if any, during the term of this authorization for the following specific …

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AUTHORIZATION FOR RELEASE OF INFORMATION

WEBTitle: Microsoft Word - aNMHC AUTH Revised - Electronic Format 9-27-2013 (2) Author: dmetz Created Date: 20131024094529Z

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~C~IRun~ Healthcare

WEB~C~IRun~ Hea1th Information 61 Emera1d P1ace Healthcare . Management Department Rock Hill, NY 12775. 155 Crysta1 Run Road 845-794-6999 Middleto wn, NY 1 094 1 Fa …

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AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL …

WEBTitle: DD Form 2870, Authorization for Disclosure of Medical or Dental Information, December 2003 Author: che Created Date: 2/26/2016 8:52:51 AM

Category: Medical Go Health

t-HS1015 DOB/GENDER

WEBauthorization for use and disclosure of protected health information page 1 of 2 hs1015 (11-14) *t-hs1015* t-hs1015 file in medical record county of los angeles department of …

Category: Medical Go Health

iIr--------------------

WEB1 0/23/201 5 1 0 :49 (fax) p.009/011 tulare county health & human services agency chol'),1 1,.d"ork •• n. ph.d .• agency dirr.c!:o,' authorization for use or disclosure of health …

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