Get Release Of Health Information Form - Pacificsource Medicare

Filling out the Release Of Health Information Form for PacificSource Medicare online can seem daunting, but with clear instructions, you can complete it efficiently. This guide will provide step-by-step assistance to ensure that all necessary information is filled out correctly.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the name of the insured whose information is to be disclosed. Enter the insured’s address, daytime telephone number, date of birth, and insured’s ID number in the designated fields.
3. In the section for persons/entities authorized to receive the personal health information, provide the name, address, phone number, and fax number of the individuals or organizations that you are authorizing to access this information.
4. Indicate the types of information you permit to be released. This includes detailed health records such as medical, dental, diagnostic imaging reports, and more. Ensure to check any additional information types that require your initials for their release, such as HIV/AIDS information, mental health information, genetic testing information, or drug/alcohol diagnosis.
5. Specify the purpose for which this information will be used in the provided space. You may also list any limitations you wish to place on the use of this information.
6. Read the acknowledgment section about your rights regarding this authorization. Here, you will also sign and date the form. If you are not the insured, select your role (parent, legal guardian, healthcare power of attorney) and attach any necessary legal documentation.
7. After completing the form, review all entries for accuracy. Save your changes, and depending on your preference, you may choose to download, print, or share the completed form.

Complete your documents online with confidence and clarity.