Get Release Of Information Form - St. Charles Health System

Filling out the Release Of Information Form is an essential step for individuals seeking to authorize the use or disclosure of their health information. This guide provides clear, step-by-step instructions on how to complete the form online, ensuring a smooth experience in managing your health records.

Follow the steps to successfully complete your Release Of Information Form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Enter your individual’s name in the designated fields, including last name, first name, and middle name. Provide your home address, including city, state, and ZIP code.
3. Fill in your date of birth in the format MM/DD/YYYY.
4. Select the St. Charles Medical Clinic groups and the St. Charles Hospital you wish to request information from by marking the appropriate checkboxes.
5. If you are requesting information from more than one clinic, fill in the additional clinic and physician names as needed.
6. Specify the date range of services by entering the start and end dates in the provided sections.
7. Indicate the purpose of your request by selecting from the options available, such as personal, legal, or continuity of care.
8. In the recipient of information section, provide the name of the physician or individual who will receive the information and choose the relevant categories.
9. List the specific type of documents you are requesting by checking the corresponding boxes. Be as specific as possible to minimize costs.
10. Read the disclosure statements carefully, and if you consent to any specific redisclosure of sensitive information, initial in the applicable spaces provided.
11. Sign and date the form where indicated. If someone other than yourself is signing, make sure to print their name and indicate the relationship to you.
12. Choose your preferred method for receiving the records, whether by pickup or mail, and provide necessary recipient details.
13. Provide your telephone number and indicate if it is acceptable to leave a detailed message.
14. Once you have completed all sections, review the form for accuracy. You can then save changes, download, print, or share the completed form as needed.

Complete the Release Of Information Form online today to ensure your health information is managed effectively.