Get Authorization Form - Lawrence Memorial Hospital

Filling out the Authorization Form for the Lawrence Memorial Hospital is an essential step in managing your protected health information. This guide will provide you with clear and structured instructions to help you complete the form online, ensuring that your authorization is accurate and effective.

Follow the steps to complete the authorization form online:

1. Press the ‘Get Form’ button to access the authorization form and open it in your preferred editor.
2. Begin by filling in your name, date of birth, and social security number in the designated fields.
3. Specify the entity or organization from which your protected health information (PHI) will be released by entering the appropriate name and address.
4. Clearly indicate the person or entity to whom the PHI will be released by filling in their name and address.
5. Outline the purpose of the disclosure by completing the corresponding section.
6. Enter the expiration date of your authorization or note that it will automatically expire 90 days from the date you sign if left blank.
7. Initial in the appropriate spaces identifying the specific types of health information you wish to authorize for disclosure, including any relevant reports.
8. List the visit dates associated with the disclosure in the provided fields.
9. Sign and date the form in the designated area to authorize the release of your information. Include your relationship to the patient, if applicable.
10. Ensure that a witness signs and dates the form, as required.
11. After all sections are filled out, save the changes made to the form. You may then choose to download, print, or share the completed document.

Take the next step by completing the authorization form online today.