Get Authorization: "general" Use & Disclosure Of Phi - Wellstar Health ... - Wellstar

Filling out the Authorization: 'general' Use & Disclosure Of PHI form is a critical step for individuals who wish to manage their protected health information (PHI). This guide provides a clear, step-by-step process to assist you in completing the form correctly to ensure your information is shared appropriately.

Follow the steps to accurately complete your authorization form.

1. Click the ‘Get Form’ button to access the authorization form and open it for completion. Ensure you have a reliable device and internet connection to facilitate this process.
2. In the first section, select the appropriate facility where you received care by placing a checkmark next to: Kennestone Hospital, Windy Hill Hospital, Cobb Hospital, Paulding Hospital, Douglas Hospital, Homecare, or Hospice.
3. Next, fill out the patient's information by providing the last name, first name, middle initial, birth date, medical record number, and social security number (optional). Make sure to print clearly.
4. Fill in the complete mailing address, including street address, city, state, and zip code. Also, provide the home phone number and any alternate phone number for contact.
5. Identify the recipient of the PHI by writing their name, organization, and telephone number. Include the complete address of the recipient, making sure to fill in suite number, city, state, and zip code.
6. Specify who is authorized to make the disclosure. This may include healthcare providers or organizations as relevant.
7. Indicate the requested dates for which the information is needed, if applicable. Specify other relevant dates where necessary.
8. Choose the specific description of PHI you wish to disclose by checking the appropriate boxes such as complete medical record, diagnostic reports, and other related categories.
9. Clearly state the specific purpose of the PHI disclosure from the given options. Options might include personal requests, referrals, legal proceedings, or other purposes.
10. Acknowledge the understanding of the potential risks and conditions associated with the authorization by reviewing the statements carefully.
11. Finally, sign and date the authorization, indicating your relationship to the patient if signing on their behalf. Ensure that two copies are made—one for the provider and one for the patient.

Complete your authorization form online today to ensure your health information is managed efficiently.