Get Individual Authorization For The Use And Disclosure Bb - Kaleida Health

Filling out the Individual Authorization For The Use And Disclosure Bb - Kaleida Health form is essential for facilitating the proper management of your health information. This guide provides clear, step-by-step instructions to ensure that all necessary information is accurately completed, keeping your privacy and rights at the forefront.

Follow the steps to complete the authorization form effectively.

1. Click the ‘Get Form’ button to access the Individual Authorization For The Use And Disclosure Bb - Kaleida Health form in the online editor.
2. Fill in your personal information in the specified fields, including your name, address, date of birth, medical record number, phone number, and financial number. Ensure that all details are accurate and up to date.
3. In the section requesting who will disclose the information, check the appropriate Kaleida Health facility which will be responsible for releasing your information. Select from the provided options such as Buffalo General Medical Center or Women & Children's Hospital of Buffalo.
4. Next, identify who will receive your information by providing the names and addresses of the person(s) or category of persons (such as a healthcare provider) to whom the information will be sent.
5. Specify what information will be disclosed by indicating the details, such as medical records and any specific types of sensitive information (if applicable) that you authorize for release, by initialing the relevant lines.
6. Indicate the reason for the disclosure by selecting the appropriate option, such as 'At the request of the individual' or entering a different reason.
7. In the expiration section, provide the date or specific event upon which your authorization will automatically expire.
8. Finally, review all entries for accuracy, then provide your signature, date, and print your name before submitting the form. Be sure to keep a copy for your records.
9. After completing your form, save your changes and you may choose to download, print, or share the form as required.

Ensure your health information is managed properly by filling out the Individual Authorization form online today!