Get Carpenterssw

Completing the Carpenters Southwest Authorization Form is an essential step for individuals seeking to authorize the Southwest Carpenters Health & Welfare Trust to use or disclose their Protected Health Information. This guide will provide you with a clear, step-by-step process to fill out the form online accurately and efficiently.

Follow the steps to complete your form smoothly.

1. Click ‘Get Form’ button to access the Authorization Form and display it in your chosen format.
2. Begin by entering your name in the designated space. Ensure that you print clearly, as your signature will be required later.
3. Specify your relationship to the member in the provided section. Options include 'self', 'spouse', or 'dependent child'.
4. Input your birth date in the specified format (MM/DD/YY).
5. Fill in the member's name related to the authorization form.
6. Enter the member’s Social Security Number or Member Number in the appropriate field.
7. Complete your address by entering your street address, city, state, and zip code.
8. Provide both your home and work telephone numbers in the indicated spaces.
9. In the section for the information you authorize to be used or disclosed, check all relevant boxes that accurately describe the Protected Health Information you want shared.
10. List the names of individuals or categories of persons who may receive this information in the space provided.
11. Clarify the purpose of the request in the designated area. If you prefer, you can state, 'At the request of the individual.'
12. Select an expiration date for this authorization. You have options for a specific date or ten years from the date of signing.
13. Read the provided information regarding the rights and conditions associated with your authorization. Acknowledge your understanding by signing and dating the form.
14. Once completed, save any changes made to the form. You can also choose options to download, print, or share the completed document as necessary.

Ensure you have completed and submitted your authorization form online for timely processing.