Get Release Of Information Form - Mercy Hospital

This guide provides clear instructions on how to complete the Release Of Information Form for Mercy Hospital online. Whether you are a patient or their legal representative, following these steps will ensure that you fill out the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the digital editor.
2. In the 'Patient Identification' section, fill in the patient's last name, first name, middle initial, birth date, social security number, medical record number, complete address, and telephone number. Ensure all information is accurate to avoid delays.
3. Next, navigate to the 'Information Being Sent To/From' section. Indicate whether the information is being released from Mercy Iowa City or to Mercy Iowa City. Enter the name of the facility or individual, their address, and contact information, including phone and fax numbers if applicable.
4. Proceed to the 'Type of Information Being Requested' section. Here, select the specific documents you wish to request. You can choose from options such as history and physical reports, discharge summaries, x-ray reports, and more. You must also indicate the date range for the requested services.
5. In the 'Specific Authorization for Release of Information Further Protected by State or Federal Law' section, initial any category of information that you do not wish to be released, such as AIDS or HIV status, alcohol and drug abuse treatment, or behavioral health services.
6. Fill out the 'Purpose for Disclosure' section by selecting the reason you are requesting the information. Options include patient care, second opinion, personal use, insurance claim, or transitioning care.
7. You are required to state acknowledgment of your understanding that this authorization can be revoked at any time. Additionally, provide an expiration date for the authorization if desired.
8. Finally, sign and date the form in the 'Signature and Date' section. If you are signing on behalf of the patient, include your relationship to the patient.
9. After filling out the form, you can save your changes, download a copy, print the form, or share it as needed.

Complete your Release Of Information Form online today for efficient processing.