Get Standard Authorization Form

This guide provides clear instructions on completing the Standard Authorization Form online for disclosing protected health information. It aims to assist users in navigating each section and field to ensure accurate and efficient completion.

Follow the steps to complete the Standard Authorization Form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering the individual’s name and information in Section I. Include details such as date of birth, group number, and identification/subscriber number. Ensure accuracy as this information is vital for identifying the correct individual.
3. In Section II, specify the persons or organizations authorized to receive the information. Include their relationship to the individual and the purpose of the information request. Make sure all details, including the address, city, state, and ZIP code, are accurate.
4. Proceed to Section III, where you must provide a specific description of the information to be used or disclosed. Complete Parts A and B, marking 'yes' or 'no' for the release of sensitive protected health information according to the provided categories.
5. In Part A, carefully select the 'yes' or 'no' option regarding the release of sensitive information, if applicable. Then, in Part B, choose one or more relevant types of protected health information to be released, ensuring all necessary details are filled in.
6. In Section IV, specify the expiration date of the authorization, choosing either one year from the date signed or another date/event. Understand your right to revoke this authorization by giving written notice.
7. Finally, complete Section V by signing the form. Provide the date of signing and, if applicable, complete the details for a personal representative. Make sure to retain a copy of the signed authorization for your records.
8. Once all sections are filled out accurately, save your changes, download, print, or share the form as needed based on your requirements.

Complete your Standard Authorization Form online today for a seamless experience.