Get Lafene Health Center

Filling out the Lafene Health Center records release form is a crucial step in managing your protected health information. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it for editing.
2. In Section 1, provide your personal identification details. This includes printing your full name, any aliases or maiden names, and your complete street address, city, state, and zip code. Also, enter your student I.D. number and date of birth.
3. In Section 2, indicate the types of records you wish to disclose by initialing the appropriate boxes. For complete medical records, initial the first option. If you only want specific records, detail them in the space provided.
4. Specify the purpose for which you want the records disclosed in Section 3. Write a brief description that clarifies your intent.
5. Fill out Section 4 by providing the name of the facility or person authorized to send the information. Ensure to include any relevant contact details that may be required.
6. In Section 5, identify the facility or person authorized to receive the information. Provide multiple lines of detail as necessary including phone and fax numbers.
7. In Section 6a, note the expiration of the authorization. If no expiration date is specified, the authorization will last for 90 days.
8. In Section 6b, reiterate the expiration date if applicable. Remember that the authorization does not exceed one year unless otherwise specified.
9. Review the consent statements at the bottom of the form, confirming your understanding of the implications of transferring your records.
10. Finally, sign and date the form in the designated areas. If you are signing on behalf of the patient, describe your relationship in the provided space.
11. After completing the form, you can save changes, download, print, or share it as necessary.

Complete your documents online now for a seamless health information management experience.