Get Authorization To Obtain And/or Disclose Health Information - Policies ...

Filling out the Authorization To Obtain And/or Disclose Health Information is an essential step for managing your health records. This guide will provide clear, straightforward instructions to help you complete the form online with ease.

Follow the steps to fill out the form accurately and efficiently.

1. Click the ‘Get Form’ button to acquire the document and open it in your preferred editor.
2. Begin by entering your personal information in the designated fields. This includes your name, date of birth, address, email address, city, state, and zip code. Ensure that all details are accurate and reflect your current information.
3. Indicate the dates of service for which you are requesting information. This helps clarify the records needed.
4. Select the specific information to be disclosed or obtained by checking the relevant boxes. Options may include discharge summaries, laboratory tests, or entire records. Be sure to include all pertinent sections.
5. If there is any information you do not want released, specify that under the ‘Please DO NOT release the following information’ section.
6. State the purpose of the information request clearly. This could be for legal reasons, ongoing care, or personal use. Completing this section is important for compliance.
7. Identify the individual or organization to whom the information should be sent, or from whom it should be obtained. Ensure you list their name, phone number, address, city, state, and zip code.
8. If you are requesting that information be obtained, provide the details of the University of Connecticut Health Center, including the provider's name and department. Correct information here ensures the timely processing of your request.
9. Include the date of expiration for the authorization form and understand that it will automatically expire six months from the date signed unless specified otherwise.
10. Finalize the form by reading the provided notices and legal disclaimers carefully. This section includes important information about your rights and protections regarding the disclosed information.
11. Once all fields are completed, review the entire form for accuracy. After confirming all information is correct, you can save changes, download, print, or share the form as needed.

Complete your paperwork online today to ensure your health information is managed seamlessly.