Get Student Nurse Assignment Form 2.doc. Advance Directive Form - Advance Health Care Directive Clinic

This guide provides clear and step-by-step instructions for completing the Student Nurse Assignment Form 2 and the Advance Health Care Directive. Whether you are familiar with medical authorization forms or not, this guide aims to support you in accurately filling out these important documents.

Follow the steps to successfully complete your form

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the patient’s full legal name, including any maiden or previous names, in the designated area.
3. Input the patient's birth date and phone number. This information is essential for identification and any follow-up queries.
4. In the section labeled 'Information Released FROM,' select only those Mayo Clinic Health System sites where the patient has received care. If another provider is to release information, document their full name and address.
5. Move to the 'Information Disclosed TO' section. Clearly print the name, address, city, state, and contact phone number of the individual, facility, or organization that will receive the records.
6. In the 'Health Information to be Released' section, check the corresponding boxes to specify what type of records should be copied. Include relevant clinical departments, illnesses, or the date range.
7. Indicate the purpose for disclosure by selecting the appropriate option in the provided section.
8. Choose the delivery method for the information, deciding whether it should be mailed, picked up by the patient or authorized designee, or another method.
9. Fill in the authorization section. The authorization is valid for one year unless otherwise specified. Please provide a signature and date, and include the relationship to the patient if signing on their behalf.
10. Finally, after completing all sections, review the form to ensure everything is accurate. Save any changes, then download, print, or share the completed form as needed.

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