Get Authorization For Release Of Information - Nebraska Medical Center

Completing the Authorization For Release Of Information form is an essential step in accessing your medical records. This guide will walk you through each section of the form, ensuring a smooth and efficient online submission.

Follow the steps to fill out your authorization form accurately

1. Click ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Begin by filling in your personal details in the designated fields, including your full name, birth date, mailing address, daytime telephone number, and Social Security Number.
3. In the section titled 'I hereby authorize and request release of my medical records,' provide the name of the healthcare facility that will be sending the information. Then, fill in the details of the individual or institution to which the information will be sent, including name, street address, city, state, and zip code.
4. Identify the specific information you wish to disclose by selecting the appropriate checkboxes corresponding to the records you need, and specify the dates for which the information is required.
5. Indicate the purpose of the release by selecting from the provided options, such as medical care, transferring care, or personal records. If necessary, specify any other purpose.
6. Review the consent statement carefully. Acknowledge that you can revoke this authorization at any time, and ensure the expiration date is filled correctly. If no expiration is noted, the authorization will last for 12 months.
7. Finally, sign the document to validate your consent, along with dating it. If applicable, have a parent, guardian, or authorized representative sign and indicate their relationship to you.
8. Once the form is completed, save your changes and proceed to download, print, or share the document as needed.

Complete your Authorization For Release Of Information form online today for seamless access to your medical records.