Get Authorization For The Release New2015final042715.docx. Biggert-waters Flood Insurance Reform Act Of

This guide provides a clear and supportive approach to completing the AUTHORIZATION FOR THE RELEASE NEW2015FINAL042715.docx. Biggert-Waters Flood Insurance Reform Act Of. By following these instructions, users will gain a comprehensive understanding of each section and field within the document, making the process of releasing information straightforward and efficient.

Follow the steps to complete the form correctly and efficiently.

1. Begin by clicking the ‘Get Form’ button to access the document and open it for editing.
2. Fill in the patient information section with accurate details. This includes the patient’s first, middle, and last name, Cleveland Clinic medical record number, current address (including city, state, and zip code), last four digits of their Social Security number, email address, and phone number.
3. In the 'Release Information From' section, indicate which Cleveland Clinic facilities will be disclosing the health information. You may check either 'Cleveland Clinic Ohio facilities' or 'Cleveland Clinic Nevada facilities'. If selecting specific Ohio locations, list them as required.
4. Provide the recipient information in the 'Release Information To' section. This includes the name of the person or organization receiving the information, their address (city, state, and zip), along with their phone and fax numbers.
5. Select the delivery method for the information by marking either 'Paper' or 'Secure electronic delivery'. If you opt for electronic delivery, be sure to enter the recipient’s email address.
6. State the purpose for the disclosure. It's important to describe why the information is being shared, such as for continuing care, personal use, or legal reasons.
7. Indicate the dates of service you wish to release by specifying the 'FROM' date and the 'TO' date.
8. Select the types of records you want to include in the release by checking the appropriate boxes, such as office visits, emergency department reports, discharge summaries, and more.
9. Read the consent statement carefully before signing. This indicates your understanding that the information may include sensitive details and that it can be re-disclosed by the recipient.
10. Once all sections are filled out completely, the patient or their personal representative should sign and date the document. If the signer is not the patient, ensure to include the relationship to the patient.
11. After completing the form, you can save your changes, download a copy for your records, print it out, or share it as needed.

Complete your document online today to facilitate the release of your health information.