Get Authorization For Release Of Medical Information - Unitypoint Health

Completing the Authorization For Release Of Medical Information form is a crucial step in ensuring that your medical records are shared with the appropriate individuals or facilities. This guide provides clear instructions on how to fill out the form online effectively.

Follow the steps to complete your authorization form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling in your name on the first line where it states 'I, ______________________.' This is the name of the person providing consent.
3. In the next section, specify the facility name that holds your medical records. You can find this information in the top portion of the form under the facility's contact details.
4. Provide the facility address and phone number in the space provided to ensure that the request is directed to the correct location.
5. Next, fill in the name of the person or facility that will receive your medical records. Include their contact information for clarity.
6. Enter your information, including your full name, any previous names, date of birth, phone number, and address in the designated spaces.
7. Select the type of records you wish to release by checking the appropriate boxes, such as 'Hospital' or 'Clinic.'
8. Specify the information requested by checking boxes next to the types of records you need, such as immunizations, x-rays, or lab results.
9. Indicate the dates for which you are requesting records by filling in the 'From' and 'To' dates.
10. Select the purpose of the request by checking the corresponding box and review all your selections to ensure accuracy.
11. Read and acknowledge the statements regarding the authorization's terms. Your initials will signify that you agree to the conditions.
12. Sign the form along with your date of signature. If a legal representative is signing, they must also provide their relationship to you.
13. A witness must sign the document, date it, and ensure it is completed correctly.
14. Once the form is completed, save your changes, download a copy, print it for physical submission, or share it as needed.

Complete your Authorization For Release Of Medical Information form online today to ensure your records are shared effectively.