Get Authorization For Release Of Information Form - Sibley Memorial ...

Filling out the Authorization For Release Of Information Form is a crucial step in ensuring that your medical information is shared as per your needs. This guide provides clear, step-by-step instructions on how to complete this form online, ensuring a smooth and effective process.

Follow the steps to complete your authorization form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your editing tool.
2. Enter the patient's name in the designated field titled 'Patient Name.' Ensure the spelling is correct and reflects the patient's identification.
3. Fill in the 'Date of Birth' field with the patient's birth date, formatted as MM/DD/YYYY.
4. Provide the patient's address in the empty lines under 'Address.' Include the street address, city, state, and zip code.
5. Enter the patient's telephone number in the 'Telephone' field, ensuring to include the area code.
6. Fill in the 'SSN' field, which stands for Social Security Number, ensuring accuracy and confidentiality.
7. Specify the period for which the information is covered by filling in the 'From' and 'to' date fields.
8. Review the list of medical reports available for release. Check the boxes next to the desired information you wish to authorize for release.
9. In the section for the recipient of the information, provide the names and addresses of the entities or individuals who will receive the disclosed information.
10. Clearly state the purpose of the information disclosure in the 'For the purpose of' section.
11. Place your signature and date on the form where indicated to authorize the release.
12. If applicable, a witness must also sign the form. Ensure that their name and relationship to the patient are recorded correctly.
13. Review all entered information for accuracy and completeness before saving your changes.
14. Once completed, download, print, or share the form as necessary.

Ensure your health information is shared accurately by completing the Authorization For Release Of Information Form online today.