Get Patient Health Information Authorization -

Completing the patient health information authorization form online is an essential step in managing your healthcare information. This guide will provide you with clear instructions to help you navigate the process effectively.

Follow the steps to successfully complete your authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the patient information section, including your name, birthdate, last four digits of your Social Security number, address, and contact numbers. Ensure all personal information is accurate and complete.
3. In the party who has my health information section, select 'Carle and any Carle entity' or specify another organization if applicable. Provide the required contact details for the organization holding your health information.
4. In the party who I want to receive or use my health information section, select 'Carle and any Carle entity,' 'Hoopeston and any Hoopeston entity,' or specify another recipient. Include their contact details as needed.
5. Indicate the purpose of use or disclosure of your health information by selecting one of the options provided, such as medical follow-up, employment reasons, or patient request.
6. Describe the health information to be disclosed by choosing one of the specified options. Be as specific as possible regarding dates or conditions.
7. Complete the expiration section. The default expiration is 90 days, but you can specify a different date if necessary.
8. Review the cancellation policy. If you need to cancel the authorization, ensure you understand the steps outlined.
9. Acknowledge the potential for re-disclosure, particularly for sensitive information such as drug or alcohol records.
10. Understand the implications of not signing the authorization. Review the fees associated with copying your health information as well.
11. Sign and date the form. If you are signing on behalf of someone else, include your authority to sign and the relationship to the patient.
12. Return the completed form to the appropriate facility listed at the bottom of the form. You can save a copy for your records.

Ensure your healthcare information manages smoothly by completing your documents online today.