Get Authorization For Disclosure Of Copies Of Protected Health ... - Texaschildrens

This guide provides a clear and supportive approach to filling out the Authorization For Disclosure Of Copies Of Protected Health Information form for Texas Children’s Hospital. Follow the steps outlined to ensure that your form is completed accurately and efficiently.

Follow the steps to successfully complete your authorization form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor for editing.
2. In the first section, fill in the patient's name, birth date, mailing address, home phone number, and city, state, and ZIP code. Additionally, specify the dates of service related to the health information requested.
3. In the second section, select the reports you wish to have disclosed by checking the appropriate boxes. Options include abstracts, discharge summaries, lab reports, and more. Specify the name of any clinic or doctor, if necessary. Indicate if any mental health records are included.
4. Next, provide the name and phone number of the individual to whom the copies should be mailed, along with their full mailing address.
5. In the fifth section, state the purpose for which the information is being disclosed. Be specific to ensure clarity.
6. Read through the authorization statement carefully. Sign your name and date the form to confirm your authorization. Include your printed name and relationship to the patient.
7. Once the form is completed, you can save any changes made, download it for your records, print a copy, or share it as necessary.

Complete your Authorization For Disclosure Of Copies Of Protected Health Information online today for a smooth processing experience.