Get Release Of Health Information Form - Osf St. Joseph Medical Center - Osfstjoseph

Filling out the Release Of Health Information Form is a vital step in ensuring that your health information is shared appropriately. This guide will provide you with step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to fill out your form correctly.

1. Press the ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by entering the patient’s full name in the designated field, ensuring accurate spelling for identification purposes.
3. Input the patient's date of birth in the section provided, following the format requested.
4. Complete the street address, city, state, and zip code fields to provide your current residence information.
5. Enter the patient’s social security number in the respective field to ensure proper identification.
6. Fill in the phone number field with the patient's contact number for any follow-up communications.
7. In the ‘I hereby authorize’ section, provide the name of the organization or individual who is authorized to disclose the information.
8. In the ‘To Disclose to’ section, enter 'OSF Occupational Health' and their address as indicated on the form.
9. Specify the nature of the information to be disclosed by checking the relevant boxes and entering the required dates.
10. Indicate the purpose of the disclosure in the provided space, being as clear and concise as possible.
11. Read and understand the patient rights section regarding information disclosure, ensuring you understand your rights.
12. Sign and date the form where indicated to validate the authorization.
13. If applicable, a parent or guardian should print their name, sign, and indicate the relationship in the designated space.
14. Choose whether to have your records mailed to the specified address or to notify you when they are ready for pickup by checking the appropriate box.
15. Make sure a staff witness signs and dates the form if required.
16. Once all fields are filled, save changes, and you may download, print, or share the completed form as needed.

Take the next step towards managing your health information by completing your form online today.