Get Authorization For Release Of Information - Scripps Health - Scripps

This guide provides clear instructions for completing the Authorization For Release Of Information form for Scripps Health. By following these steps, users can effectively authorize the release of their protected health information in a secure and organized manner.

Follow the steps to complete your authorization form.

1. Press the ‘Get Form’ button to access the authorization form and open it for editing.
2. Carefully read the preliminary instructions on page 1. Ensure you understand the implications of authorizing the release of your health information. Initial the statement indicating that you have read and understood these terms.
3. On page 2, fill in your personal details in the specified fields, including your name, date of birth, and social security number.
4. Identify the record holder by providing their name and full address in the designated fields.
5. Specify where the records will be released to by filling in the recipient's name and address, including the phone and fax numbers if applicable.
6. Select the date range for the records you are requesting, entering the 'from' and 'to' dates of service in the appropriate fields.
7. Indicate the location of treatment by checking the relevant box: inpatient, emergency, or outpatient.
8. Limit the types of information requested by checking the relevant boxes that outline the specific medical records or types of information you would like to authorize the release of.
9. If applicable, indicate any special categories of information, such as HIV test results or psychiatric records, by checking the relevant boxes.
10. Describe the purpose of the information release by checking the appropriate box related to your needs, such as personal, insurance claim, or continuing care.
11. Sign the authorization, providing your printed name, signature, and the date. If someone other than yourself is signing, indicate their relationship to you.
12. If needed, have a witness sign the form, and if it's appropriate, include the attending physician's name and date.

Complete your authorization form online today to ensure the timely release of your health information.