Get Ok Kempton Group Hippa/protected Health Information Release Form 2018

Completing the OK Kempton Group HIPAA/Protected Health Information Release Form online can streamline the process of managing your health information. This guide will provide clear, step-by-step instructions to help you accurately fill out the form.

Follow the steps to complete the form easily and accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the 'Patient Details' section, provide your full name (first, middle, last), date of birth, address (street address, city, state, zip code), plan ID number, social security number, email address, and telephone number.
3. If the patient is under 18 years of age, fill out the 'Guardian or Legal Representative' section with the guardian's or representative's name, address, telephone number, and email address. If not applicable, leave this section blank.
4. In the 'Release of PHI' section, authorize the use or disclosure of your protected health information (PHI) by specifying who can disclose the information (The Kempton Group Administrators, Inc. or the Plan Administrator).
5. Identify the person or class of persons who may receive your PHI by writing their name in the designated space.
6. Clearly describe the specific information that should be disclosed. Be concise and meaningful in your description.
7. Indicate whether you authorize the disclosure of mental health information by selecting 'Y' for yes or 'N' for no.
8. Indicate whether you authorize the disclosure of psychotherapy notes ONLY by selecting 'Y' or 'N'.
9. Indicate whether you authorize the disclosure of any alcohol or substance abuse information and/or psychotherapy notes by selecting 'Y' or 'N'.
10. Complete the 'Person/Organization to Release Information' section by providing the contact details of The Kempton Group Administrators, Inc., including address, phone number, and email.
11. Specify the expiration of this authorization by entering a date or event that will terminate it, or leave it blank to have it valid for 12 months.
12. Finally, sign and date the form to confirm your authorization. If you are a guardian or legal representative for a patient under 18 years of age, fill out your name and relationship in the provided fields.
13. After filling out all sections, save, download, print, or share the form as needed.

Get started and complete your OK Kempton Group HIPAA/Protected Health Information Release Form online today.