Get 877 302 7338

This guide provides a comprehensive overview of filling out the 877 302 7338 form online. This authorization form is essential for individuals seeking to release their protected health information in a secure and efficient manner.

Follow the steps to complete the form online successfully.

1. Click ‘Get Form’ button to obtain the form and access it in an editable format.
2. Fill in Section A with the patient’s name, birth date, phone number, and social security number (last four digits only). Provide the provider’s name and address if available, as well as the recipient’s name, phone number, and address.
3. Include the email address only if you prefer email delivery of the information. Specify the request delivery method, which can be a paper copy or electronic media.
4. Indicate the expiration date or event for the authorization, noting that it typically expires in 90 days unless otherwise specified.
5. Clarify the purpose of disclosure by providing a brief explanation of why the protected health information is needed.
6. Mark whether the request includes psychotherapy notes. If applicable, follow guidance for obtaining these specific notes.
7. Under the description section, select the items being requested for disclosure based on your needs, taking care to avoid unnecessary requests to prevent additional fees.
8. Initial next to the consent to release if the information may include sensitive content such as substance abuse or psychiatric information.
9. Complete Section B only if the request is for marketing purposes and involves compensation, providing a brief explanation if applicable.
10. In Section C, sign the form and provide the date and printed name. If signed by a guardian or representative, include their relationship to the patient.
11. After filling out the form, save your changes. You can choose to download, print, or share the completed form as necessary.

Complete the 877 302 7338 form online today and ensure your health information is handled securely.