Get 630 873 8748

Filling out the 630 873 8748 form is an essential step for requesting the release of health information from DuPage Medical Group. This guide will provide you with step-by-step instructions to help you navigate the form efficiently and accurately.

Follow the steps to effectively complete the form online.

1. Press the ‘Get Form’ button to access the 630 873 8748 form and open it in the online editor.
2. Begin filling out the 'Patient Information' section by providing your full name, date of birth, address, telephone number, and city/state/ZIP.
3. Under the 'Authorization' section, enter the name of the individual or organization to whom you are authorizing the release of your records along with their address and city/state/ZIP.
4. Select your preferred method of delivery by checking the appropriate box for US Mail, secure electronic delivery (if applicable, provide an email address), or for pick up by the patient or their legal representative.
5. If choosing pickup, indicate a site from which you would prefer to collect your records and provide the name of the person picking up the records, if not you.
6. Select the purpose of the disclosure by checking the relevant box among options such as continuation of care, personal reasons, insurance, legal, or other. You may specify further details where applicable.
7. In the 'Information Requested' section, be specific about the records you are requesting. Check off the relevant boxes, detailing the specific types of information required.
8. If applicable, initial beside sensitive information disclosures that you consent to release, and ensure you provide authorization where a minor's consent is required.
9. Complete the signatures section, providing your signature, date, and any required details from a guardian or representative concerning the patient.
10. Finally, review all sections for accuracy before saving changes, downloading, or printing the completed form for submission.

Complete your documents online for a streamlined experience!