Get Nemours Authorization Form - Nemours

The Nemours Authorization Form allows individuals to authorize the use and disclosure of their protected health information. This guide provides a step-by-step approach to ensure that you fill out the form correctly and efficiently.

Follow the steps to complete the Nemours Authorization Form.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. In the 'Patient' section, enter the patient’s name, date of birth, phone number, and address. This information is crucial for identifying the individual whose health records are being authorized for disclosure.
3. Specify how you would like to receive the medical records by selecting an option from the available choices: CD, paper, or email. If you select email, be sure to enter the appropriate email address.
4. In the 'Release medical records from' section, provide the name and email address of the facility or person from whom you are requesting records. Include the facility's address, city, state, zip code, and phone and fax numbers.
5. In the 'Disclose medical records to' section, fill in the required information about the facility or person to whom the records should be sent. This should match the format used in the previous step.
6. Indicate the dates for which you are requesting medical records by specifying a start date and an end date. You also have the option to request all records.
7. In the 'Information to be disclosed' section, detail the specific medical records you are requesting. This may include items such as lab reports, imaging reports, and outpatient clinic notes.
8. State the reason for requesting the release of medical information in the 'Purpose of disclosure' section. Options may include continuing care or personal use.
9. Complete any necessary initialing for the release of sensitive information, if applicable. This may include psychiatric notes or specific lab results.
10. Specify an expiration date or event for the authorization. If this section is left blank, the authorization will remain valid for 90 days from the date of signing.
11. Sign the form in the 'Authorization' section and ensure you enter the printed name and date. If required, include the relationship to the patient.
12. If applicable, have a witness sign and date the form as well.
13. Once all sections are completed, review the form for accuracy, then save, download, or print the form as needed.

Complete your authorization form online today to ensure your health records are handled promptly.