Get Authorization For Release Of Health Information - Iona College - Iona

Filling out the AuThorizATion For ReleAse Of HeAlTh InformATion form at Iona College allows you to authorize the release of your protected health information. This guide will provide you with a step-by-step approach to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the authorization form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Enter the patient’s last name, first name, and middle initial in the designated fields.
3. Input the date of birth, current address, city, state, and zip code.
4. In the section labeled 'Information to be disclosed', select the appropriate boxes for the records you wish to release, including any specific dates of service if applicable.
5. Fill out the contact information of the individual or organization to whom the health information will be disclosed, ensuring to provide their name and address.
6. Review the section detailing your understanding of this authorization, including your right to revoke it and the conditions under which it will expire.
7. Specify the purpose of the disclosure by checking the relevant boxes that apply to your situation.
8. Sign the form, provide your printed name, and date it to confirm your authorization.
9. Once completed, save your changes, and you may choose to download, print, or share the form as necessary.

Complete your health information release authorization online today.