Get 04mp001e

Filling out the 04mp001e form is a crucial step in authorizing the use and disclosure of your protected health information. This guide will walk you through each section of the form, ensuring you complete it accurately and efficiently.

Follow the steps to fill out the form online:

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the patient's name in the designated fields. Fill in the last name, first name, middle initial, and any maiden or other names.
3. Input the date of birth in the format designated (MM-DD-YYYY) and list any former names as applicable.
4. Fill in both day and evening phone numbers for contact purposes.
5. Authorize the disclosure of protected health information by selecting the preferred method of receipt (mail or hold for pickup) and providing the recipient's details including name and relationship.
6. Indicate the information to be released by checking the appropriate boxes and specifying any additional requests for content or dates.
7. Include the purpose of disclosure by marking the relevant reasons listed in the options.
8. Acknowledgment of understanding requires initialing each statement to confirm that you are aware of the terms related to your authorization.
9. Finalize the form by providing your signature, date, and relationship to the patient, ensuring all necessary information is completed.
10. Review the completed form for accuracy, and then save changes, download, print, or share the document as needed.

Complete your documents online for a more efficient experience.