Get 2005 Authorization Form.doc. Disclosure Authorization Form

This guide provides clear and comprehensive instructions on how to fill out the 2005 Authorization Form.doc. Disclosure Authorization Form online. By following these steps, you can successfully complete the form and ensure your health information is shared as per your wishes.

Follow the steps to fill out your authorization form online.

1. Press the ‘Get Form’ button to obtain the document and open it in your preferred online editor.
2. Enter your full name in the designated field, ensuring your name matches the records held by the health provider.
3. Provide your Regence ID number, which helps link your authorization to your personal health information.
4. Input your date of birth to confirm your identity.
5. Authorize the disclosure of specific types of information by checking the relevant boxes: enrollment and eligibility information, claims and claim history, medical records, premium and billing information, and psychotherapy notes. If you do not want any sensitive information disclosed, do not check the respective box.
6. List the names and addresses of the individuals or entities to whom this information will be disclosed.
7. State the purpose of the disclosure, selecting 'to assist me with my health plan' or another purpose if applicable.
8. Note that the authorization is valid for two years, and specify an end date if desired, ensuring it does not exceed the two-year limit.
9. Acknowledge that you can cancel this authorization at any time by providing written notice.
10. Sign and date the form in the appropriate section to validate your authorization.
11. If applicable, complete the section for a personal representative acting on your behalf, including their name, phone number, and their relationship to you.
12. After reviewing the filled form for accuracy, save your changes, download a copy for your records, print it, or share it as needed.

Complete your 2005 Authorization Form online today to ensure your information is handled according to your preferences.