Get Hipaa Certification Form

Filling out the Hipaa Certification Form online is a straightforward process that enables users to authorize the release of their protected health information securely. This guide provides detailed instructions to assist you in completing each section of the form accurately.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in your full name in the ‘Patient Name’ field. This should be your legal name as it appears on your medical records.
3. In the ‘Date of Birth’ section, enter your birthdate in the format of month, day, and year.
4. Next, provide your ‘Social Security Number’ in the designated field to ensure proper identification.
5. Indicate the ‘Date of Service’ by writing the exact date when the services were provided.
6. Specify the ‘Purpose of Request’ by providing a brief description of why you are authorizing the release of your medical records.
7. Below the purpose, enter the name of the person or organization to whom your records will be sent in the ‘Name of Person/Organization’ field.
8. Fill in the 'Address' of the recipient to ensure accurate delivery of your information.
9. You will see a list of records that can be disclosed. Select the option that applies to you by checking the appropriate box. Options include 'Complete medical record(s)', 'Discharge Summary', among others.
10. If applicable, indicate any sensitive information you do not want released by checking the relevant boxes.
11. Review the authorization statement and your rights regarding revocation of consent. This ensures you understand your rights and responsibilities.
12. Finally, provide your ‘Signature’ and the ‘Date’ of signing the form. Also, indicate your ‘Relationship to patient’ if you are not the patient completing the form.
13. After completing the form, you can choose to save changes, download a copy, print for your records, or share the authorization with the recipient.

To ensure your medical records are disclosed promptly, complete the Hipaa Certification Form online today.