Get Authorization For Disclosure Of Protected ... - Aspirus - Aspirus

Filling out the authorization for disclosure of protected health information is a crucial step in managing your health records. This guide provides clear, step-by-step instructions to help you accurately complete the form and ensure your information is handled appropriately.

Follow the steps to complete the authorization form correctly.

1. Press the ‘Get Form’ button to access the authorization form and open it within the editor. This will allow you to begin filling it out digitally.
2. Enter your personal information in the specified fields. This includes your full name, date of birth, address, city, state, zip code, previous last names (if any), and phone number.
3. Specify the individuals or organizations to whom your health information will be disclosed. Fill in their names, organizations, and addresses in the designated areas.
4. In the section labeled 'Information to be disclosed', indicate which types of health information you authorize for disclosure by initialing the appropriate boxes.
5. Complete the 'Dates of Service' section, providing the relevant dates for which the information is being disclosed.
6. Choose the purpose for the disclosure from the options provided. Mark the appropriate box to indicate why you are allowing this information to be shared.
7. Review the section regarding further disclosure and the rights to revoke and review the authorization. This is important to understand your rights regarding your health information.
8. Fill in the expiration date for your authorization, which is effective for six months from the date signed unless otherwise indicated.
9. Sign and date the form where indicated, ensuring you also include the signature of a parent or legal representative if required.
10. Finally, save your changes, download, print, or share the completed form as needed.

Complete your authorization form online today for seamless management of your health information.