Get Fmla Hipaa Authorization Form

Filling out the FMLA HIPAA Authorization Form online is a straightforward process that ensures your health information is shared appropriately with relevant parties. This guide provides clear, step-by-step instructions to help users navigate the form efficiently.

Follow the steps to complete your FMLA HIPAA Authorization Form online

1. Click the ‘Get Form’ button to access the FMLA HIPAA Authorization Form and open it for editing.
2. In the first field, print the name of the patient or their legal representative who is authorized to act on their behalf.
3. For the healthcare provider section, enter the name and address of the physician, clinic, or healthcare provider who is releasing your health information.
4. Provide the phone number of the healthcare provider in the designated field.
5. Fill in the patient's name and, if applicable, the employee's name if it is different from the patient.
6. Select the purpose of the release by checking the appropriate box to indicate if it is for the employee’s own leave, their child, spouse, or parent.
7. Enter the name of the employee's supervisor at UAMS and include the mail slot number for proper delivery.
8. Specify the type of information to be released, ensuring it is limited to the reason the employee is requesting leave under FMLA.
9. Note the expiration of the authorization, which will last for one year from the date of signing or until the leave request is no longer active.
10. Understand your right to withdraw the authorization at any time by providing written notice to the designated healthcare provider.
11. Recognize that once information is disclosed, it may be re-disclosed by the recipient and may not be protected by federal privacy laws.
12. Sign and date the form to complete the authorization.
13. If signed by a legal representative, indicate their relationship or authority to act on behalf of the patient in the designated space.
14. Finally, save changes, download, print, or share the completed form as needed.

Begin filling out your FMLA HIPAA Authorization Form online today for a smooth submission process.