Get Authorization For Release Of Information - Community Health Network

Filling out the Authorization For Release Of Information form is a crucial step in allowing your medical records to be shared with authorized parties. This guide will provide you with clear and concise instructions on completing this form online, ensuring that you can efficiently manage your health information.

Follow the steps to complete your Authorization For Release Of Information form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient name in the designated field. Ensure the spelling is accurate as this will be used to identify the records.
3. Input the patient's Social Security number in the corresponding section. This information is vital for proper identification.
4. Fill in the patient's street address, city, state, and zip code in the respective fields. Ensure that this information is up-to-date.
5. Enter the patient's date of birth and provide a telephone number or cell number for contact purposes.
6. Acknowledge your agreement to the release of health records by reviewing the information provided in the section. Make sure you understand the implications of signing.
7. Designate the individual or organization to whom the information will be released by filling in their name and address.
8. If applicable, specify the individual or organization from whom information is to be obtained, including their name and address.
9. Select the purpose of the disclosure from the options available. If you have another reason, please specify it in the provided space.
10. Indicate the dates of information to be disclosed. You can choose a range, specific dates, or select all records.
11. Outline the specific information to be disclosed by ticking the relevant boxes related to your medical records.
12. Sign and date the authorization form. If necessary, a parent, guardian, or representative should also sign it in the designated area.
13. Identify a witness for the signature section, and ensure they also date the form.
14. Finally, review all filled-out information for accuracy before saving changes. You can download, print, or share the completed form as needed.

Complete your Authorization For Release Of Information form online today to ensure seamless management of your health records.