Get Loyola Authorization For Release Of Health Information

Filling out the Loyola Authorization For Release Of Health Information is a critical step in ensuring your medical records are shared with the intended parties. This guide provides clear instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully fill out and submit your authorization form.

1. Press the 'Get Form' button to access the Loyola Authorization For Release Of Health Information form. This will allow you to view and edit the document as needed.
2. Begin by entering your personal information in the designated fields. This includes your full name, telephone number, address, date of birth, and the last four digits of your social security number.
3. Indicate which organization you are authorizing to release your health information by selecting one of the following options: Loyola University Medical Center, Gottlieb Memorial Hospital, or another specified facility. Provide the name and address of the chosen entity.
4. Fill in the details of the person or facility to whom you want your health information released. Be sure to include their full name, telephone number, and complete address.
5. Specify the dates of treatment or services for which you are requesting records to be released.
6. Indicate the purpose for the release of your health information by providing a brief description in the space provided.
7. Check the relevant boxes for the types of information you wish to be released, including lab results, outpatient records, and more. Be sure to specify any additional information if needed.
8. Complete Section A if your health information includes any sensitive categories, such as mental health or substance abuse records. You must sign to acknowledge your understanding of the implications of this release.
9. In Section B, specify the expiration date for the authorization. The date must be completed for the request to be processed.
10. Provide your signature and the date at the end of the form. If you are signing on behalf of the patient, state your relationship and provide the necessary proof of authority.
11. If applicable, include witness signatures as required if the patient is unable to sign the form.
12. If you are an attorney making this request, complete Section C by checking the relevant boxes and providing necessary information and signatures.
13. Review all details for accuracy. Once everything is complete, you can save your changes, download, print, or share the completed form as necessary.

Complete your documents online today to ensure your health information is handled with care and precision.