Get Attachment 46 (english) - Office Of Hipaa Privacy & Security - Privacyoffice Med Miami

Filling out the Attachment 46 form is a crucial step in authorizing the disclosure of your health information to third parties. This guide provides clear and comprehensive instructions to help you complete this form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to acquire the form and open it in your preferred text editor.
2. In the first section, identify the person or persons you authorize to use or disclose your health information. Provide the name of the medical records department or specific healthcare provider.
3. Next, specify the recipient of the information in the designated field. Include their name and relationship to you, such as family member, attorney, or employer.
4. Provide the contact details of the recipient, including the address and phone number, ensuring that any necessary details, like the city and state, are correctly filled in.
5. In the following section, describe what information you authorize to be used or disclosed. Be specific about the type of health information you wish to share.
6. If applicable, initial next to any specific health information categories that you are authorizing for disclosure, such as HIV/AIDS status or mental health treatment records.
7. Indicate the purpose for which this information will be used or disclosed in the next field.
8. If the disclosure is for marketing purposes, note the relevant covered entity and provide the necessary information.
9. Set an expiration date for this authorization. If left blank, it will automatically expire one year from the signing date.
10. Finally, sign and date the form. Include your full name, address, contact phone number, and last four digits of your social security number.
11. After completing the form, save your changes, and choose to download, print, or share it as needed.

Complete your documents online to ensure a seamless process.