Get 8556680697

Filling out the 8556680697 form is essential for providing authorization for the disclosure of protected health information. This guide will walk you through each section of the form to ensure it is filled out accurately and efficiently.

Follow the steps to complete your form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section A, enter the patient’s name, date of birth, provider’s name, recipient’s name, patient’s phone number, and the last four digits of the Social Security Number if desired.
3. Fill in the provider's address, including address line one (700 West Oak Street, Kissimmee, FL 34741) and any additional address details if needed.
4. Provide the recipient’s phone number and fax number, and fill in the city, state, and zip code.
5. Select a request delivery method. You may opt for a paper copy, electronic media, encrypted email, or unencrypted email. Note the risks involved with unencrypted delivery.
6. If you chose electronic media or email for delivery, print your email address legibly.
7. In the expiration section, either fill in a date or an event indicating when the authorization will expire, but not both.
8. Specify the purpose of the disclosure and provide a description of the information to be used or disclosed.
9. Indicate if the request is for psychotherapy notes. If yes, the form is limited to this request only; if no, check other applicable items.
10. Acknowledge understanding by initialing next to the statement about the content of the information.
11. In Section C, provide the signature of the patient or their representative, the date, and print the name of the representative along with their relationship to the patient.
12. Once completed, you can save changes, download, print, or share the form.

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