Get 1-ws0465* *1-ws0465 - Wellstar Health System - Wellstar

Filling out the 1-WS0465 form for the WellStar Health System is an essential step in authorizing the privileged use and disclosure of your protected health information. This guide will provide clear and straightforward instructions to help you complete the form accurately.

Follow the steps to complete the 1-WS0465 form effectively.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Select the appropriate facility by checking the box next to your desired location, such as Kennestone Hospital, Cobb Hospital, or Homecare.
3. In the Physician's Group section, provide the name of your practice if applicable, or select 'Other' and fill in the name.
4. Complete the Patient Information section by printing clearly. Include your last name, first name, middle initial, birth date, and full street address. Optionally, you can include your medical record number or social security number.
5. Fill in the Release Information To section with the name of the person or organization receiving the information, including their contact details and address.
6. List any individuals or organizations authorized to make the disclosure in the corresponding field.
7. Specify the requested dates for the information release, including any additional relevant dates.
8. Indicate the items related to your health information that require special authorization by checking the relevant boxes.
9. Provide a specific description of the protected health information to be used or disclosed by checking the relevant boxes.
10. Select the specific purpose of the disclosure request from the provided options.
11. Review the authorization statement and ensure you understand your rights regarding the use and disclosure of your privileged health information.
12. Sign and date the form, ensuring to include any necessary information about your relationship if you are not the patient.
13. Indicate the expiration date for the authorization. If not specified, it will automatically expire 90 days from the date signed.
14. Finally, save your changes, download a copy, print the form, or share it online, if needed.

Complete your 1-WS0465 form online today to ensure timely processing of your health information authorization.