Get Authorization To Disclose Protected Health Information Docx

This guide provides clear and supportive instructions on how to fill out the Authorization to Disclose Protected Health Information form online. By following these steps, you can ensure that your health information is disclosed appropriately and securely.

Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the document and open it for editing.
2. Enter your full name in the designated field at the top of the form.
3. Provide your Regence ID number, followed by your date of birth in the specified areas.
4. Indicate the information you authorize to be disclosed by selecting the relevant options such as enrollment, eligibility, benefit information, or medical records.
5. Identify the specific person(s) or entity(ies) to whom the information will be disclosed by filling in their names and addresses.
6. Provide the phone numbers of the individuals or entities listed for direct communication.
7. State the purpose for the disclosure in the provided section. You may choose an option or outline a specific reason.
8. Note the validity period of the authorization, which can be up to two years, and write in the end date if necessary.
9. You may cancel this authorization at any time. If needed, make a note of how to do this.
10. Sign and date the form at the bottom. If another person is signing on your behalf, make sure to fill out their information accordingly.
11. Review the completed form for accuracy before saving or printing. You can download or share it once finalized.

Complete your documents online to ensure efficient management of your health information.