Get Authorization Form - Ecmc.edu - Ecmc

Filling out the Authorization Form is essential for granting permission to use and disclose your protected health information. This guide will assist you in navigating each section of the form comprehensively and clearly.

Follow the steps to complete the Authorization Form accurately.

1. Click the ‘Get Form’ button to obtain the Authorization Form and open it for editing.
2. Begin by entering your personal information in the designated fields. This includes your patient or resident name, date of birth, address, social security number, and phone number. Ensure that all information is accurate and up to date.
3. In the section labeled 'I hereby authorize the use or disclosure of protected health information as follows,' indicate what information you authorize to be used or disclosed by initialing the applicable lines. This can include all treatment records as well as specific records such as behavioral health, drug and alcohol treatment, or HIV-related records.
4. Next, specify the time period for the records by initialing the corresponding line. Ensure to provide accurate information based on your medical history.
5. Fill out the section regarding expiration of the authorization. You can choose a specific date or define an event that will terminate the authorization.
6. Identify who may disclose this information by entering the name of the person or entity providing the information.
7. Specify to whom the information may be disclosed. Include names, addresses, and phone numbers of the individuals or agencies.
8. Clarify the purpose for the disclosure by detailing your reason. Options may include a request from you or your personal representative.
9. Review the section that describes your right to revoke the authorization and how to do so. Understand that this may involve contacting the facility’s Privacy Officer.
10. Check the understanding that the information disclosed may be re-disclosed by the recipient, noting necessary exceptions.
11. Acknowledge your right to refuse to sign the form and how it will not affect your healthcare or benefits.
12. Lastly, sign and date the form, providing your printed name and the description of your authority if you are a personal representative.
13. Upon completing the form, save any changes made. You can also download, print, or share the form as needed.

Complete your Authorization Form online today to manage your health information securely.