Get Mc3165 - Auth To Communicate Minor's Health Information.doc. Greening Action Guide & Toolkit

Filling out the MC3165 form is essential for authorizing the communication of a minor's health information to family members and other individuals. This guide provides clear and supportive instructions to assist users in accurately completing the form online.

Follow the steps to successfully complete the form.

1. Click the ‘Get Form’ button to access the MC3165 form and open it in your preferred online editor.
2. Begin by providing your child’s name in the designated field to ensure accurate identification.
3. Enter the minor's date of birth in the specified format to verify the patient's age.
4. Provide the social security number of the minor to enhance identification and processing.
5. Fill in the medical record number, if available, to facilitate access to health records.
6. Clearly list the names of individuals with whom health information will be shared. Include all necessary individuals and their relationships to the minor.
7. Select the type of information that can be shared by marking the relevant checkboxes, such as scheduling, medical billing, and appointment details.
8. Describe any legal proceedings that might affect the right of individuals to access the patient's information, if applicable.
9. Specify any instructions or limitations you may have regarding information sharing in the provided field.
10. Enter a validation code to ensure authorized individuals can access the health information securely.
11. Affix the signature of the parent or legal guardian, along with the date, to confirm authorization.
12. Lastly, save changes, and consider downloading or printing the completed form for your records. You may also share it with relevant parties as needed.

Complete the MC3165 form online today to ensure your child's health information is communicated to the right individuals.