Get Authorization Form (.pdf) - Myphr

Filling out the Authorization Form is a crucial step in allowing the disclosure of your health information. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently, ensuring that your privacy and preferences are respected.

Follow the steps to efficiently complete the Authorization Form.

1. Click the ‘Get Form’ button to access the Authorization Form (.pdf) and open it in your preferred editing tool.
2. In the first field, enter the patient's name as it appears on their identification.
3. Next, fill in the patient’s date of birth to help identify their health information.
4. Authorize the disclosure by indicating specifically who is authorized to make the disclosure in the designated section.
5. Specify the types of health information you want to be disclosed by checking the appropriate boxes. You may add additional information where prompted.
6. List the individuals or organizations that will receive the disclosed information, including their name and address.
7. Indicate the purpose of the disclosure by checking the relevant boxes to clarify how the information will be used.
8. Acknowledge your rights by reading and understanding that you can revoke the authorization and how it can be done.
9. Specify an expiration date for the authorization; if left blank, it will expire six months from the signing date.
10. Understand that once the information is disclosed, it may not be fully protected by privacy laws.
11. Provide your signature or that of your legal representative along with the date of signing.
12. If signed by a legal representative, indicate the relationship to the patient.
13. Obtain a witness signature and date in the designated area.
14. Finally, distribute the copies as indicated: original to the provider, a copy to the patient, and a copy for the use or disclosure.

Complete your Authorization Form online today to manage your health information seamlessly.