Get Authorization For Communication Of Protected Health Information To ... - Info Kaiserpermanente

Filling out the Authorization For Communication Of Protected Health Information form is a key step in ensuring that your protected health information can be shared with trusted individuals. This guide provides clear instructions to help you complete the form effectively, ensuring that your preferences are accurately communicated.

Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to access the Authorization For Communication Of Protected Health Information form online.
2. Enter your personal information in the designated fields, including your nickname, maiden name, health record number, date of birth, phone number, and address (street or box number, city, state, and ZIP code). Ensure that all information is accurate and up to date.
3. In the section requesting authorization for communication, list the names of individuals you wish to share your health information with. For each person, provide their relationship to you and a contact phone number. Be thorough in this section to ensure that all relevant parties are included.
4. Select the type of information you would like to be shared or disclosed. You can choose from options such as appointment information, prescription information, or select 'ALL information' to cover everything.
5. Indicate your preferences for leaving detailed phone messages regarding your medical and health plan information. Choose either 'Voicemail' or 'Person answering' based on your comfort level.
6. Review all entered information for accuracy. Ensure that all required fields are completed, and the details are correct.
7. Sign your name as the patient or authorized individual, and date the form. This signature is necessary for the authorization to take effect.
8. Once completed, save the form digitally, or print it for mailing. You can mail the completed form to Health Information Files – Process Center, or fax it as indicated in the document.

Complete your Authorization For Communication Of Protected Health Information form online today to ensure that your health information is shared with the people you trust.