Get Authorization For Release Of Information - Wvu Healthcare

Completing the Authorization for Release of Information form is an essential step for individuals seeking to manage their medical records with WVU Healthcare. This guide will provide you with clear, step-by-step instructions to ensure that the process is straightforward and accessible.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to access the Authorization for Release of Information form and open it in your preferred editing application.
2. Fill in the patient name by entering the last name, first name, and middle initial in the designated fields.
3. Provide the patient's address, including the city, state, and zip code in the appropriate sections.
4. Enter the patient's phone number, birthdate, and Social Security Number (SSN), which will assist in identifying the patient if necessary.
5. Indicate the purpose for releasing information by checking appropriate boxes such as 'Self', 'Insurance', 'Workers Comp', or 'Disability'.
6. Specify how the information should be delivered by choosing from options such as 'Mailed to Patient', 'Hand Carried', or 'Mailed to Physician or other Health Care Provider'. If 'Hand Carried', include the name of the individual picking up the records and remember that photo ID is required.
7. Complete Section 3A by writing the name and address of the facility where the records should be directed, along with the phone number and fax number.
8. Select the specific medical records to be released by checking the corresponding items, including options like 'History and Physical', 'Laboratory Results', and 'X-Ray Reports'. You may also provide other specific instructions if needed.
9. Indicate the time period of the records you are requesting by filling out the 'covering record time period' section.
10. In the section regarding confidentiality, indicate any types of records that should not be released by checking the appropriate boxes.
11. Check whether records are inpatient or outpatient by selecting corresponding boxes for various departments and specialties.
12. Sign and date the form to confirm your authorization and ensure that the signature is provided by a legal representative if applicable.
13. Review all entries for accuracy, then save changes, download, print, or share the completed form as required.

Start your document completion process online today.