Get Initiation Of Services Form - Florida Department Of Health

The Initiation Of Services Form, provided by the Florida Department Of Health, is a crucial document for establishing a client-provider relationship and authorizing the use of personal medical information. This guide will offer step-by-step instructions on how to complete the form online effectively.

Follow the steps to complete your form submission online.

1. Press the ‘Get Form’ button to access the Initiation Of Services Form. This action will open the form in your designated editor, allowing you to fill it out as needed.
2. Begin with Part I, where you will provide your client name, the name of the agency providing services, and the agency address. Make sure all details are accurate to avoid any delays.
3. Review and understand the consent information provided in Part I regarding the client-provider relationship to ensure you know your rights regarding confidentiality and voluntary participation.
4. Proceed to Part II to consent to the disclosure of your medical information. Ensure you understand what types of information are included, such as medical, dental, and psychological records.
5. If you are a Medicare client, fill out Part III, providing your certification and authorization to release necessary medical information. Confirm that all information provided is correct.
6. For clients utilizing third-party payers, complete Part IV by assigning your benefits to the agency named earlier. Be aware of your financial responsibilities for any uncovered charges.
7. In Part V, sign the form to verify that the information you provided is accurate and that you have received the notice of privacy rights. Include the date and the relationship to the client for clarity.
8. If you choose to withdraw your consent at any time, complete Part VI, providing your name, date of withdrawal, and a signature, as well as a witness signature if necessary.
9. Finally, review your completed form for accuracy. Once satisfied, save your changes. You can also download, print, or share the completed form as needed.

Complete your Initiation Of Services Form online today to establish your healthcare provider relationship!