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To Complete Blank Authorization To Release Information Form, Follow the Steps Below:

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Hand-in-Hand Teaching Guide to create Blank Authorization To Release Information Form

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How to employ The Blank Authorization To Release Information Form?

hello Dave Guerra real record service.how are you thank you for stopping by.today to watch this video today I'm.going to talk about the authorization to.release health information form it's.usually a one-page document.I know another medical document you have.to fill out but you know what this is.for your own protection because again.this lets the hospital the private.practice or the clinic know what you.need why you need it and who accessed it.and who gave it to you the whole nine.yards which is a good thing especially.when your privacy is at stake.so ideally I'm going to go over the farm.from top to bottom and what I'm looking.at or what you're gonna see is you show.up at the medical records department at.the clinic or the doctor's office you.say hey I need a copy of my medical.records well they're gonna hand you a.form typically like I said one page now.they might go into - it just depends on.your location there might be your state.might require additional notifications.that's okay that's strictly up to them.so but for the most parts I've.encountered one-page documents and.usually cram everything in there but.please read the entire document before.you fill it out again.read the entire document before you.start putting your name on that piece of.paper now at the top of the form should.say the practice the hospital or the.clinic that's it has the information.next there should be a title and bold.letters will say authorization and.disclose protected health information.authorization to disclose medical.records authorization to release.protective wealthwise percent protected.or health information or medical.information again then the next section.would be your name we're not necessarily.your name the patient's name and that.would be like the legal representative.you would be the legal representative.you would need to put the patient's name.down there we go sorry about that and.then you put the patient's full name not.like Jake you actually put Jacob not.Tony unless that's what it is in his.birth certificate nats how they signed.in you would put anthony otherwise the.date of birth now you may be asked for.additional information that's okay.because again how many Jon semester in.the world and how many John Smith's.share the same birthday.so again now you might be asked like I.said for additional information this.would typically be like your address or.your social security number maybe like.the last four digits or if you have a.medical record number that's okay if you.don't no problem between you and the.medical record clerk you guys you will.definitely drill down to get exactly.your information the next section will.be where you or the legal representative.of the patient will authorize the.facility the hospital the clinic the.private practice and will be written on.there or in some cases you have to fill.it out yourself that's okay and you.authorize them to disclose the.information relating to the above-named.individuals health information in this.case the patient then type in a type the.type and the amount of information to be.used as listed below now what this is is.what you're asking for here you.typically there's gonna be some boxes.you can check in or you can actually.write in what you're looking for you.would type in you would check off like.the operative report or the history and.physical discharge summary pathology.reports lab reports EKG results whatever.and then you would put down the date now.here's here's here's the thing if you're.not too sure say this happened in 2010.and you just now need it for some reason.then what you would do is you'd put May.2010 the month that it showed up and.then between you and the medical records.clerk or the release of information.Support Specialist you would drill down.exactly the dates of service if you.arrived three times in that month of May.2010 which is the one you need now there.are some cases and mostly this is in.disabilities or in for well for your own.peace of mind your very first time you.might want to ask for any and all any it.all covers every visit you've ever had.to the hospital or the clinic or the.private practice and all dates inclusive.all everything now this could get pretty.lengthy that could come up a little bit.costly but we'll talk about price at a.different time but just to know in some.locations there are fees next you once.you determine what you need and when you.needed it from you would check off.what's this for what are you gonna use.this information is it for continuation.of care meaning you're going to another.visit another doctor or specialist as is.for personal like I said some people.nowadays one.all the information all their personal.health information all in one place in.their possession you'll get a copy of it.it says for an attorney is this for.Medicaid Medicare uh you're requesting.that you're you want to get proof for.that is this for insurance so the.insurance you question something or.you're dealing with the insurance for.the first time or a third party.insurance like a plaque again this is.what you would check off is this for a.disability determination or if there's.another reason you should fill that in.you go a little further down now here's.for all the disclaimer stuff goes into.you you understand that the information.may include some drug and health and.mental health treatment mental health.services as part of your entire medical.record you understand that it could be.inclusive you also understand that you.have the authorization to revoke it at.any time and we're talking about the.release this form you can revoke the.time if you don't put a specific dates.that you only wanted for a week.by default it goes to six months here in.the state of Texas 180 days from the day.you sign it and then at that point that.form can't be used anymore for that.specific reason at that specific event.so you might need to fill out another.form typically it's good practice every.time you go in to fill out a new form it.just makes things a little bit easier.and it make things well not so difficult.when it tries to determine if we've or.if we or the release of information such.as the hospital the clinic has already.released that information so something.to think about there follow not follow.fill out the form every time you come in.requesting information one doesn't carry.over to the necklace so say you went in.from May 2010 you fill out the form you.want the information from May 2010.you're gonna have to fill in another.form for June 2010 without a doubt said.about the revocation and you understand.at the very bottom this should be some.disclaimer that says you voluntarily are.signing this form you voluntarily filled.out this form you voluntarily understand.that you want this information disclosed.and you understand that once this.information has been released so you.release it to a hospital a third party.it won't well it can't be pulled back.once it's out there and this is so long.as this form is there this form is added.to your medical record history and it.says that on this date you arrived or so.your legal representative arrived and.they fill out the form and they sent it.to this clinic so again all of that.stays there and.the hospital or the electronic medical.record system will keep track of who.accessed it why it was accessed in this.case to release the information to you.and who requested it in this case you.were your legal representative lastly at.the very bottom you're going to sign it.the patient will sign or the legal.representative if the legal.representative signs there should be.some supporting documentation with them.now something you should know just.because you're a spouse does not.automatically make you a legal.representative of the patient say there.was an emergency room visit and your.spouse was out fishing and got into a.fishing accident had to go to the ER and.your son or daughter was with your.spouse and that's who checked them into.the hospital well at that time that who.becomes a legal representative of the.patient because for some reason your.spouse was not able to sign was unable.to fill in their information that's who.signed them in to get that treatment so.it's like I said just because you're the.spouse does not automatically make you.the legal representative now this can.vary but in state of Texas that's the.way it is does not automatically make.you a legal representative and I'll go.more into legal representatives in a.future video and it's coming so don't.worry the last thing you need to do is.reread everything make sure all the form.all the blanks are filled in all the.dates are provided the informations.there and then at the very end after you.sign it please date it with today's date.don't back date it don't future don'ts.predate it future dating don't don't.predate don't post date and sign it.today's date because that's what's gonna.get entered into the system if you sign.something with tomorrow's date and it.gets entrance in the EMR system there's.gonna be some questions somebody's gonna.wonder why you or your legal.representative predated or post-dated.your form your request other than that.if you've got questions please drop me a.note dave at our RS online and our.website is real wreck his real record.service our RS online us that's our web.address I do invite you to visit thank.you for your time have a good day.

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