Get Authorization For Release Of Health Information - University Of ...

This guide provides users with a clear and supportive approach to completing the Authorization for Release of Health Information form for the University of Mississippi Medical Center. By following the steps outlined here, you can effectively ensure your health information is released as needed.

Follow the steps to complete your authorization form clearly and accurately.

1. Press the ‘Get Form’ button to obtain the Authorization for Release of Health Information form and open it in your document editor.
2. Begin by filling in the name of the physician, physician group, or hospital that is authorized to release your health information.
3. Input the name and contact information of the person whose health information is to be released. Include the patient’s name, Social Security Number (SSN), date of birth, complete address (P.O. Box, Apt. No., street, town, state, and zip), and a contact phone number.
4. If the University of Mississippi Medical Center (UMMC) is releasing your health information, provide the details of the person or class of persons to whom the health information will be sent. Include their name, address, and phone number.
5. Indicate the reason for the release of information and the specific date by which the information is needed.
6. Describe in detail the health information to be released. Be specific in detailing items such as physician notes, x-rays, operation records, and account information.
7. Review the authorization expiration notice, which states that the permission to release the information is valid for six months unless otherwise indicated.
8. Finally, sign and date the document, ensuring all information is complete and accurate before signing. If applicable, provide a description of the personal representative's authority.
9. Once completed, you can save changes, download, print, or share the form as needed.

Complete your authorization form online to ensure your health information is released correctly.