Get Authorization For Release Of Protected Health Information - Wpahs

The Authorization For Release Of Protected Health Information - Wpahs is a vital document used to allow the West Penn Allegheny Health System to share your protected health information with designated individuals or organizations. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently online.

Follow the steps to complete the authorization form correctly.

1. Click the ‘Get Form’ button to access the document and open it in your preferred editor.
2. Enter the patient's full name in the designated fields, ensuring to include the last name, first name, and middle initial.
3. Provide the date of birth of the patient in the corresponding field.
4. Fill in the complete address of the patient, including street, city, state, and zip code.
5. Identify the recipient of the health information by specifying the Physician Organization or another entity that will receive the information.
6. Authorize the release of specific types of health records by checking the appropriate boxes, such as allergy lists, lab results, or radiology results.
7. If applicable, indicate any health information that should not be released by checking the boxes for HIV, mental health, and drug or alcohol-related information.
8. Specify the time frame for which the records are to be requested by filling in the 'From' and 'To' date fields.
9. Select the reason for the request by checking the corresponding box and filling in any additional details, if necessary.
10. Indicate the expiration of the authorization by either selecting six months or specifying another expiration date, event, or time frame.
11. Sign the form, including the date and the relationship to the patient if signing on their behalf. A witness may also need to sign if required by policy.
12. Once all sections are accurately completed, save changes to the document. You can also download, print, or share the completed form as needed.

Take the time to complete your Authorization For Release Of Protected Health Information - Wpahs online today.