Get Records Release Form - Palouse Medical

Completing the Records Release Form is an essential step for granting permission to share your health information. This guide offers clear instructions on how to accurately fill out the form online, ensuring your needs are met effectively.

Follow the steps to complete your Records Release Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the patient's name and date of birth in the designated fields at the top of the form. If the patient has a previous name, include that in the appropriate space as well.
3. Indicate who may request or disclose the protected information by selecting the appropriate checkbox and writing in the name of the individual or organization in the relevant section.
4. Provide the address, city, state, and zip code of the individual or organization receiving the health information.
5. Next, specify the health care information that the authorization applies to by checking all relevant options. Options include all health care information, information related to specific treatments or conditions, or specific date ranges.
6. If applicable, check any disclosures that require specific authorization, such as those for HIV/AIDS or mental health. Be aware that minors may need to provide signatures for certain disclosures.
7. State the reason for the authorization to disclose health care information by selecting the most appropriate checkbox and providing additional details if necessary.
8. Indicate the expiration of the authorization by selecting one of the options available: a specific date, an event, or after 90 days.
9. Lastly, sign the form, including your printed name and relationship to the patient if applicable. If a minor's signature is needed, ensure this is completed in the designated area.
10. Once you have filled out the form completely, save your changes. You may then download, print, or share the completed form as needed.

Complete your Records Release Form online today to ensure your health information is properly managed!