Get Consent For Release Of Medical Information - Halifax Health

Filling out the Consent For Release Of Medical Information form from Halifax Health is an essential step in ensuring the proper handling and sharing of your medical information. This guide will walk you through each section of the form, facilitating a smooth online completion process.

Follow the steps to accurately complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. Begin by filling out the name of the person requesting the release of information at the top of the form.
3. Next, provide the patient's name and medical record number to ensure the correct records are being requested.
4. Complete the address and phone number fields to establish contact information.
5. Enter the patient's date of birth, as well as the date you need the information by. Indicate whether the information should be mailed or picked up.
6. Authorize Halifax Health Medical Center to send your records by filling in the name of the facility and the doctor’s name receiving the information.
7. Provide the required contact details for the facility, including fax number, phone number, and shipping account number, if applicable.
8. Specify the street address, city, state, and ZIP code for the location where the records should be sent.
9. Detail the specific information you wish to be released from your medical record, such as pathology reports, slides, blocks, or tissue.
10. List the dates of service relevant to the requested information.
11. Select the purpose for the release of information from the provided options and, if applicable, specify any other reason.
12. Read through the authorization details regarding the potential inclusion of sensitive information and indicate if you do not want certain information shared.
13. Sign the form, indicating whether you are the patient or a legal representative, and date your signature.
14. If signed by a legal representative, provide a description of your authority to act on behalf of the individual.
15. Finally, after ensuring all fields are correctly filled out, save your changes, and proceed to download, print, or share the completed form.

Complete your documents online to manage your medical records with ease.