Get Riverside Community.pdf - Getrecords

This guide provides detailed steps on how to effectively complete the Riverside Community.pdf - GetRecords form online. It aims to assist users in navigating through each section of the form with clarity and support.

Follow the steps to accurately fill out the form online.

1. Press the ‘Get Form’ button to access the Riverside Community.pdf - GetRecords form and open it for editing.
2. In Section A, provide the patient or plan member's name, birth date, and social security number (optional). Next, fill out the provider or health plan's name and address.
3. Enter the recipient's name, phone number, fax number, and address in the designated fields.
4. Specify the expiration date or event for this authorization to remain valid. You must fill in either a specific date or a designated event, not both.
5. Indicate the purpose of the information disclosure by checking the appropriate box and providing a description of the information you want to be used or disclosed.
6. If requesting psychotherapy notes, check 'Yes.' If not, check 'No' and select any relevant items from the list provided.
7. Initial the acknowledgment that the released information may include sensitive information such as alcohol, drug abuse, or psychiatric details.
8. Read and understand the statements regarding the voluntarily nature of signing the authorization and the revocation of it at any time.
9. In Section B, answer whether the PHI request is for marketing purposes and, if yes, provide necessary details.
10. In Section C, verify your ID, sign the form, and provide the date. Ensure the printed name and relationship to the patient or plan member are also filled out.
11. Once completed, save the form, download, print, or share it as needed.

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