a file upload want to Canvas nints 6 Authorization Assignment Assess the following authorization form against the Privacy Rule criteria and determine if any element(s) is/are missing List the elements that are found missing Patient's Name: Date of Birth: Patient's Social Security Number: I hereby authorize Pine Valley Medical Center to release to the following: Name: Address: Documents to be released are: From Date of Service: Purpose for record request is: I understand that this authorization will be in effect for one year from the date of my signature, unless otherwise noted, and that I may revoke this authorization in writing and submitted to the Health Information Management Department. I understand that applicable laws may prohibit redisclosure of this information, but that PVMC will not be liable or responsible for any redisclosure that takes place after the information has been released. I understand that I will not be denied treatment if I refuse to sign this authorization. I understand that I am entitled to a copy of this authorization. I understand that the information will be handled confidentially in compliance with applicable state and federal laws. I have read and understand the nature of this release. Patient's Signature/Legal Representative Date Witness Date a file upload want to Canvas nints 6 Authorization Assignment Assess the following authorization form against the Privacy Rule criteria and determine if any element(s) is/are missing List the elements that are found missing Patient's Name: Date of Birth: Patient's Social Security Number: I hereby authorize Pine Valley Medical Center to release to the following: Name: Address: Documents to be released are: From Date of Service: Purpose for record request is: I understand that this authorization will be in effect for one year from the date of my signature, unless otherwise noted, and that I may revoke this authorization in writing and submitted to the Health Information Management Department. I understand that applicable laws may prohibit redisclosure of this information, but that PVMC will not be liable or responsible for any redisclosure that takes place after the information has been released. I understand that I will not be denied treatment if I refuse to sign this authorization. I understand that I am entitled to a copy of this authorization. I understand that the information will be handled confidentially in compliance with applicable state and federal laws. I have read and understand the nature of this release. Patient's Signature/Legal Representative Date Witness Date