Due to the need to ensure that the nine required elements necessary in a HIPAA compliant authorization are contained in release of information requests (our form #48 and HIPAA Policy 0P7.1), Strong Health/Health Information Management has asked that this form not be altered. If the pre-printed 'generic' form #48 (SMH or HH version) does not clearly identify your mailing address and phone numbers, contact Joe Cassera at 249-7709 at Moore Wallace. Joe will coordinate obtaining/printing form # 48 with your location specific information.
A sample of this form can be viewed here.