Get Authorization Form - Providence Washington

This guide provides step-by-step instructions for completing the Authorization Form for Providence Washington. It aims to assist you in correctly filling out the form to request copies of medical records in a secure and efficient manner.

Follow the steps to complete the Authorization Form online.

1. Click ‘Get Form’ button to obtain the Authorization Form and open it in your preferred editor.
2. Fill in your name in the space provided, clearly stating the full name of the person requesting the information.
3. Indicate to whom the information will be released by writing the name of the hospital or physician.
4. In the patient information section, enter the patient's name, date of birth, social security number, and the dates of treatment relevant to the request.
5. Select the records you wish to be released by checking the appropriate boxes under the Records to be Released section.
6. Specify the purpose of disclosure, selecting from options such as personal, attorney, insurance, or continuing health care. If 'Other' is chosen, provide a brief explanation.
7. Sign and date the form in the designated area, ensuring that you also identify your relationship to the patient.
8. Indicate whether identification was checked by marking the relevant option (yes, no, or refused).
9. After completing the form, ensure to save your changes, and then proceed to download, print, or share the completed form as needed.

Complete your Authorization Form online today to efficiently access your medical records.