Get Authorization To Release Protected Health Information - Yumaregional

Filling out the Authorization To Release Protected Health Information form is an essential step in managing your health records. This guide provides a clear and supportive overview to help you navigate the online completion of this important document.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and open it in an online editor.
2. In the first section, enter the patient’s name and date of birth accurately. This identifies the individual whose health information will be released.
3. Next, select whether you authorize Yuma Regional Medical Center to release information for a specific service period by filling in the dates or for a single event by providing the relevant date.
4. Specify the exact type of protected health information to be disclosed by checking the relevant boxes. Include any necessary dates, particularly for visits or tests.
5. Indicate whether you authorize the provider to disclose information related to genetic testing, behavioral health, alcohol or drug abuse treatment, and AIDS/HIV by checking and initialing the appropriate boxes.
6. Acknowledge your understanding that treatment is not conditional on signing this authorization. This statement clarifies your rights regarding the disclosure of your information.
7. Complete the expiration section by indicating either an event or condition that will signify the end of the authorization's validity.
8. Sign and date the form as the patient or have a legal representative sign it, including their relationship or authority description.
9. Review the completed form for accuracy. Once you are satisfied with your entries, save the changes, and choose to download, print, or share the form as needed.

Start filling out your Authorization To Release Protected Health Information form online today!