Get Authorization For Release Of Medical Information Form - Uncpn

Filling out the Authorization For Release Of Medical Information Form - Uncpn online is a straightforward process that ensures your medical information is shared securely and efficiently. This guide provides step-by-step instructions to help you complete the form accurately.

Follow the steps to complete the form online seamlessly.

1. Press the ‘Get Form’ button to access the Authorization For Release Of Medical Information Form - Uncpn and open it in your editing tool.
2. In the section labeled 'I authorize:', choose one between 'UNC Physicians Network' or enter the name of another person or facility authorized to disclose your medical information.
3. Fill in the address, city, state, and ZIP code of the authorized person or facility, along with the phone number and email address if available.
4. In the 'To use or disclose to:' section, enter the name, address, city, state, ZIP code, and phone number of the person or facility that will receive your medical records.
5. Complete the personal information for the patient, including their name, date of birth, address, phone number, and treatment dates. Include the medical record number and the last four digits of the social security number.
6. Check the square boxes next to the specific documents you wish to request to be released, such as clinic notes, lab reports, or other relevant documents.
7. Initial the boxes next to any sensitive information you authorize to be released, such as mental health records or information related to HIV/AIDS.
8. Select the purpose of your request by placing a checkmark next to one of the options provided.
9. Choose how you would like to receive your requested information by marking the appropriate option for mail, email, fax, or in-person pickup.
10. For the signature section, ensure to provide the signature of the patient or an authorized representative, along with their printed name and date. Specify the authority of the representative if applicable.
11. Review all the information filled out in the form for accuracy before submitting. You may then save changes, download, print, or share the completed form as necessary.

Complete your documentation online to ensure a smooth release of your medical information.