DHS-25M-CL Rev. 4/05 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES CLIENT S NAME Department of Human Services Dear Healthcare Provider The attached is the new DHS Authorization for Disclosure/Use of Health Information Form DHS25M. Section VI Specific information the patient does NOT want disclosed. 9. A copy of the completed Form DHS-25M will be given to the patient. Specific Information I do NOT want disclosed check the applicable box es Laboratory.
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How to fill out the Dhs 25m online
Filling out the Dhs 25m form correctly is essential for the proper authorization of health information disclosure. This guide provides a clear and user-friendly approach to completing the form online, ensuring you understand each section and field.
Follow the steps to successfully complete the Dhs 25m form online.
- Use the ‘Get Form’ button to access the Dhs 25m form and open it for editing.
- In Section I, enter the name of the person whose health information is to be disclosed. This should be completed accurately to avoid any issues.
- Proceed to Section II, where you need to fill in the name and address of the person or organization that is authorized to release the information, as well as the name and address of the recipient.
- In Section III, state the reason for requesting the disclosure of information. Options may include applying for medical assistance or personal reasons.
- In Section IV, check one box indicating the type of information to be disclosed. This includes selecting the entire health record or specifying certain sections. Ensure your choice is clear.
- Complete Section V by providing your signature and date. If applicable, include the signature of an authorized representative, noting their relationship to the patient.
- Finally, review Section VI to indicate any specific information you do not wish to be disclosed by checking the relevant boxes.
- Once all sections are completed, ensure you've saved changes, then download, print, or share the form as needed.
Complete the Dhs 25m form online to ensure timely and accurate processing of your health information disclosure.
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