Get Uwh1280490

Filling out the Uwh1280490 form is essential for authorizing the disclosure of medical information. This guide provides step-by-step instructions to help you navigate the online form seamlessly, ensuring you can complete it accurately and efficiently.

Follow the steps to successfully complete the Uwh1280490 form online.

1. Click ‘Get Form’ button to access the document and open it in your preferred editor.
2. Provide patient information in the designated fields, including the patient’s name, address, medical record number, birthdate, and phone number.
3. In section 2a, specify which records to be released by selecting one of the options: UW Hospital and Clinics, UW Medical Foundation Clinics, or both.
4. In section 2b, describe the medical records to be disclosed, ensuring your description is clear so that the patient understands what they are permitting to be used. Choose a preferred format for receiving the records.
5. Complete section 2c by indicating if all radiology images are needed or if specific images related to particular studies or dates should be requested.
6. Fill out section 3 by indicating the person or groups who will be allowed to disclose the medical information.
7. In section 4, specify the individual or groups outside the entity who may receive the disclosed information.
8. Articulate the purpose for the disclosure in section 5 by checking all applicable categories provided.
9. Indicate an expiration date or event in section 6, noting that a specific event must be related to the patient or the purpose of the authorization.
10. Sign the form in the designated area; if signed by someone other than the patient, include their relationship and authority. Ensure to provide a copy of the signed authorization form to the patient.
11. Finally, save any changes made to the form, and choose to download, print, or share the form as necessary.

Complete your documents online for a smooth and efficient process.