Get Authorization For Release Of Health Information - Office Of The State ... - Osc State Ny

Filling out the Authorization For Release Of Health Information form is an essential step in managing your health records effectively. This guide provides a clear, step-by-step process for completing the form online, ensuring you can authorize the release of your health information accurately and securely.

Follow the steps to fill out your authorization form online.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Begin by entering the patient's full name in the designated field.
3. Fill in the patient's date of birth to further identify the individual.
4. Complete the social security number section, noting that only the last four digits are required.
5. Provide the patient's current address to ensure proper communication.
6. Indicate whether you are the patient or an authorized representative by checking the appropriate box.
7. In item 6, list the names and addresses of the healthcare providers or entities that are authorized to release information.
8. In item 7, specify the name and address of the person or category of person to whom the information will be sent.
9. In item 8(a), select the specific information to be released by initialing the boxes next to the appropriate options.
10. If applicable, initial item 8(b) to authorize discussion of health information with your attorney or governmental agency.
11. Provide the reason for the release of information in space provided under item 9.
12. If someone other than the patient is signing the form, include their name in item 11.
13. In item 12, indicate your authority to sign on behalf of the patient if necessary.
14. Finally, ensure all fields are completed, sign the form, and date it before submitting.

Complete your form online now to manage your health information with ease.