Get Release Of Information Form - Adena Health System - Adena

Filling out the Release Of Information Form from Adena Health System is an essential step for accessing or sharing vital health records. This guide will provide you with clear instructions on how to complete the form accurately and efficiently online.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to access the Release Of Information Form and open it for editing.
2. Begin by filling in the patient’s personal information, including their name, date of birth, social security number, telephone number, and address in the designated fields.
3. In section 1, authorize the use or disclosure of the patient’s health information by including details of the entity or individual you are giving permission to in section 2.
4. Specify the type of information to be released in section 3 by checking the appropriate boxes and including relevant dates for records such as the problem list, medication list, and lab results.
5. In section 4, indicate if any of the specified health services include sensitive information by checking 'YES' or 'NO'.
6. State the purpose for the release of records in section 5, choosing from listed options or adding a description as necessary.
7. Acknowledge and understand your rights regarding the authorization in sections 6, 8, and 9, ensuring you are aware of the revocation process and privacy concerns.
8. Complete section 7 by specifying the expiration date for this authorization, or indicate if you prefer the authorization to expire one year from the date of signature.
9. Sign and date the form at the bottom, ensuring that if a representative signs for the patient, their relationship to the patient is noted and any necessary documentation is attached.
10. Review all the information for accuracy before saving changes, then choose to download, print, or share the completed form as needed.

Complete your documents online today to ensure efficient handling of your health information needs.