Get Date Request Completedfaxed

Filling out the Date Request Completed/Faxed form is an essential step in authorizing the release of protected health information. This guide provides clear, step-by-step instructions on how to complete this form online, ensuring that all necessary information is accurately provided.

Follow the steps to complete your form successfully

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. In Section A, fill in the patient's name and birth date in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Enter the provider's name and the recipient's name in the relevant fields. These are important for directing the authorized release of information.
4. Provide the last four digits of the patient's social security number and their phone number. This information assists in further verification.
5. Fill in the provider's address, including the street address, city, state, and zip code. This ensures that the request reaches the correct healthcare provider.
6. Indicate the expiration of the authorization by filling in either a date or an event, but not both. If left blank, the authorization will expire 180 days after signing.
7. Select the purpose of disclosure by checking the appropriate box and providing a description of the information to be disclosed.
8. If applicable, indicate whether this request involves psychotherapy notes by checking the 'Yes' or 'No' box.
9. Specify the descriptions and dates of the protected health information items being requested, checking as many items below as necessary.
10. In the acknowledgment section, agree to the potential inclusion of sensitive information by providing your initials or checking the relevant box if not applicable.
11. Read and understand the statements regarding your rights and the nature of the authorization, ensuring to note your right to refuse and revoke the authorization.
12. If the disclosure pertains to marketing, complete Section B by providing the required information; otherwise, proceed to Section C.
13. In Section C, provide the signature of the patient or their representative along with the date and the printed name of the representative, including their relationship to the patient.
14. After completing the form, review all entries for accuracy, then save changes, download, print, or share the form as needed.

Complete your documents online today for a seamless experience.