Get Information Release Of Billinig Information Form

Filling out an Information Release Of Billing Information Form online is a straightforward process. This guide provides step-by-step instructions to ensure you complete the form correctly and efficiently.

Follow the steps to successfully complete the form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the necessary personal details in the provided fields, including your unit number, name, and birthdate.
3. In the authorization for release section, indicate the purpose of the release by checking one or more boxes such as continuity of care or billing.
4. Specify the name of the person or facility that will receive your health information. If applicable, include their street address, city, state, and zip code, as well as a fax number if the information is to be faxed.
5. Detail the specific health information you authorize to be released by selecting the types and dates of treatment.
6. Important: Identify the additional sensitive information that requires additional authorization by marking the corresponding boxes if you wish to release any of it.
7. Fill in the expiration of authorization section by inserting the applicable date or event, noting that it will expire 12 months after signing if no date is provided.
8. Print your name, sign the form, indicate your relationship to the patient, and complete the date and time fields.
9. If necessary, a witness or interpreter can also sign in the appropriate fields, but this is only required if the patient is unable to sign.
10. Once you have filled out all necessary sections, save the changes, and download the document as needed for your records or to share.

Complete your documents online today to streamline your information management process.