Get Patient Profile Request Auth Form - Giant

Filling out the Patient Profile Request Auth Form is a straightforward process that allows users to request access to their prescription history. This guide aims to provide clear and supportive instructions for completing the form online, ensuring a smooth experience.

Follow the steps to successfully complete your Patient Profile Request Auth Form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient's name in the designated field. Ensure that the spelling is accurate, as this will be used for identification purposes.
3. Next, provide the patient's date of birth. This information helps to confirm the identity of the individual requesting the prescription history.
4. Complete the patient's address section. Include the street address, city, state, and zip code to ensure proper processing of the request.
5. Input the daytime phone number where the patient or their representative can be reached. This contact information may be needed for verification.
6. Fill in the store name where the prescription was filled and the corresponding store address. This helps in directing the request to the correct pharmacy location.
7. In the section to describe the health information to be disclosed, specify the time period for the prescription profile. If additional information is needed, check the 'Other' box and provide a description.
8. Indicate the recipient of the disclosed information by selecting either 'Myself' or providing the name of a family member authorized to receive it.
9. Review the authorization expiration date, which defaults to sixty (60) days after signing. If a different expiration is needed, indicate it accordingly.
10. Finally, sign the form as either the patient or their personal representative. Include the date of signing along with the representative's name and relationship to the patient if applicable.
11. Once all fields are completed, you can save changes, download a copy, print, or share the form as needed.

Start your online document request today by filling out the Patient Profile Request Auth Form.