Get Rm-0211-1216

The RM-0211-1216 form is used to authorize the disclosure of hospital records for determining eligibility for disability retirement. This guide provides clear, step-by-step instructions to help you fill out the form accurately and effectively online.

Follow the steps to fill out the RM-0211-1216 form online:

1. Click ‘Get Form’ button to access the RM-0211-1216 form and open it in your preferred editor.
2. Enter the patient’s name and date of birth in the designated fields.
3. Provide the patient's address and telephone number accurately to ensure proper contact.
4. Identify the entity you are authorizing to release health information by filling in the name of the hospital, workers’ compensation center, or employer.
5. Indicate the source of records by selecting the appropriate checkbox for hospital records, employer’s doctor’s evaluations, or workers’ compensation center.
6. Specify the dates of treatment from which information is to be disclosed, ensuring accuracy in these details.
7. Select which documents are to be included by checking the appropriate boxes, such as discharge summary, progress notes, or other relevant records.
8. Read the statement regarding the nature of the information being disclosed and ensure you understand its implications.
9. Provide your signature along with the date to officially authorize the release of records.
10. Once you have completed the form, save your changes, download, print, or share the form as needed.

Complete your RM-0211-1216 form online today for efficient handling of your authorization.