[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-563654-105":53,"doc-detail-563654-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","authorization-to-disclose-protected-health-or-billing-information-form","Authorization to Disclose Protected Health or Billing Information - Form","","Authorization form enabling release of protected health or billing information from specified SCR acute facilities and clinics to designated recipients. Collects patient identity and contact details, treatment date range, and the purpose for disclosure. Allows selection of full record, treatment summary, or partial items such as physician notes and orders/results. Includes delivery method options, potential fees notice, acknowledgement of cancellation, redisclosure risk, and the form’s 90-day expiration, with provisions for minors, representatives, and interpreter services.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-to-disclose-protected-health-or-billing-information-form/563654/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-to-disclose-protected-health-or-billing-information-form/563654.png","ImageObject",442,249,{"name":88,"@type":89},"supergirl","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-19","2026-10-12",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information does this authorization form collect from the patient?","Question",{"text":108,"@type":109},"It collects patient name, address, email, date of birth, and the last 4 digits of SSN, along with treatment dates to be released and the purpose for the release.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What options are available for what parts of the record can be released?",{"text":113,"@type":109},"You can request a treatment summary (abstract), a partial record by selecting physician notes and orders/results, or the entire record excluding psychotherapy notes.",{"name":115,"@type":106,"acceptedAnswer":116},"How long is the authorization valid and can it be canceled?",{"text":117,"@type":109},"The authorization expires 90 days after the signature date unless another date or event is written. It can be canceled at any time by submitting written cancellation to the releasing facility or practice.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},563654,1792420472,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},962088121634,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Authorization to Disclose Protected Health or Billing InformationFor Use by SCR Acute Facilities and ClinicsPatient Information:I give permission to release the health information of:(One patient per form)  \nPatient Name:                                                                    \nStreet Address:  \nCity,State,Zip:                                                        \nEmail address:  \nAIthough Novont Health will sereasonoble means to protect the security and confidentialityofemais sent and received,we cannot guarantee the security and  \nconfidentiality of all email communications.  \n\n| Release Information From:   |  | Release Information To:   |\n| --- | --- | --- |\n| (list applicable Facility(s)and/or Practice(s))   |  | (Name of facility,person,company)  \u003Cbr>(Relationship)   |\n|  |  | (Street address or PO Box,City,State,Zip code   |\n|  |  | (Phone number)  \u003Cbr>(Fax number)   |\n\nPurpose of Release (check reason):      Reauest of individual /personal    Insurance    Disability     Workers Compensatio  \n# □ Legal purpose including discussions &proceedings□ Other:_\n\nMust fill in dates of treatment for records to be released:Treatment dates FROM  \n\n| CHOOSE ONE:I would like the parts of my record selected below to be released:   |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n| Option 1:  \u003Cbr>□Treatment Summary  \u003Cbr>(Abstract)  \u003Cbr>*includes all physician  \u003Cbr>notes,  \u003Cbr>orders and results from  \u003Cbr>the location and dates of  \u003Cbr>service indicated above.   | OR   | Option 2:  \u003Cbr>Partial Record (choose specific items below if vou do not need the  \u003Cbr>entire chart or abstract)  \u003Cbr>Physician Notes:  \u003Cbr>□All □History &Physical □Progress Notes □Office Notes  \u003Cbr>□Discharge Summary □Operative/Procedure Notes □ER  \u003Cbr>Notes  \u003Cbr>□Consultation Notes □Immunization Summary*lncludes available  \u003Cbr>limmunizations documented in the medical records chart only.Not an official state copy  \u003Cbr>Orders and Results:  \u003Cbr>All □Cardiac/EKG □Laboratory □Diagnostic Testing  \u003Cbr>Radiology/X-ray □Pathology □Medications  \u003Cbr>Other:   |  | OR    | Option 3:  \u003Cbr>□Entire Record  \u003Cbr>(not including  \u003Cbr>psychotherapy notes)   |\n| Additional Options:   |  |  | Send Completed Form To:   |  |  |\n| Billing Information  \u003Cbr>Certification of Records  \u003Cbr>d          nCIu  \u003Cbr>□Radiology Images (CD)  \u003Cbr>*CDs containing radiology image   | Estimates  \u003Cbr>Certification and Affidavit of Records  \u003Cbr>s are separate from a medical records CD and charges apply   |  | Mailing Address:25 Hospital Centre Blvd.  \u003Cbr>Hilton Head island,SC 29926  \u003Cbr>Email:ROINovantHealthSC@datavant.com  \u003Cbr>Phone (Toll Free)1-800-367-1500Fax 843-410-2724   |  |  |\n| Delivery Method:A fee may be charged for providing the protected health information.Please visit our website for a list of fees  \u003Cbr>www.novanthealth.org/medicalrecords   |  |  |  |  |  |\n| □MyChart(only available to patients)□NH LINK (only available to 3rd party)□Fax□E-mail □Paper Copy via USPS  \u003Cbr>□CD/DVD  \u003Cbr>□Other:  \u003Cbr>Patient Waiting lonsite pick un)*Novant Health clinics and hospitals may only be able to release a limited amount of records onsite.All othe  \u003Cbr>requests are processed by the Novant Health Enterprise Release of Information department.   |  |  |  |  |  |\n\nl understand that:  \n·I can cancel this permission at any time.I must cancel in writing and send or deliver cancellation to releasing facility or practice namedabove.Any cancellation will apply only to information not yet released by facility or practice.  \n·  This is afull release including information related to behavioral/mental health,drug and alcohol abuse treatment (in compliance with 42CFR Part 2),genetic information,HIV/AIDS,and other sexuall transmitted diseases,unless limited by the above selections.  \n·Once my health information is released,the recipient may disclose or share my information with others and my information may nolonger be protected by federal and state privacy protections.  \nRefusing to sign this form will not pre","cbCaip4N71QPSzh5","https://ap.wps.com/l/cbCaip4N71QPSzh5","pdf",850729,"English","# Patient Information\n## Release Information From / To\n## Purpose of Release and Treatment Dates\n## Select Record Scope\n## Send Completed Form To\n## Delivery Method and Fees\n## Patient Acknowledgements, Expiration, and Signature\n## Minor or Authorized Representative and Interpreter Options","[{\"question\":\"What information does this authorization form collect from the patient?\",\"answer\":\"It collects patient name, address, email, date of birth, and the last 4 digits of SSN, along with treatment dates to be released and the purpose for the release.\"},{\"question\":\"What options are available for what parts of the record can be released?\",\"answer\":\"You can request a treatment summary (abstract), a partial record by selecting physician notes and orders/results, or the entire record excluding psychotherapy notes.\"},{\"question\":\"How long is the authorization valid and can it be canceled?\",\"answer\":\"The authorization expires 90 days after the signature date unless another date or event is written. It can be canceled at any time by submitting written cancellation to the releasing facility or practice.\"}]","Authorization to Disclose Protected Health or Billing Information - Form | PDF",1791837030]