Get Hch375 - Policies For Uconn Health

Filling out the HCH375 form is an essential step for authorizing the photographing and recording of patients for non-clinical care purposes at UConn Health. This guide provides clear and detailed instructions to help you complete the form accurately and effectively.

Follow the steps to complete the HCH375 form online.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the patient's name in the designated space for 'Patient Name (print name)'. Make sure to provide the full name as it appears in official documents.
3. Next, input the name of the UConn Health employee responsible for this authorization in the 'UConn Health Employee Responsible' field.
4. Review the purposes for which the photographs or recordings may be used. Check all applicable boxes, ensuring you understand each purpose, including internal and external uses.
5. If applicable, describe the specific purpose(s) for the authorization in the space provided. Be as detailed as necessary to clarify the intended use.
6. Indicate if a qualified interpreter was used for individuals with limited English proficiency by checking the appropriate box and providing the necessary details.
7. For telephone consent, provide the name of the person giving consent, their relationship to the patient, and complete the section of the witness.
8. After completing all sections of the form, ensure that the patient or authorized representative signs and dates the authorization.
9. Lastly, sign the form as the UConn Health employee who obtained consent, making sure to include the date and time.
10. Once all sections are completed, review the form for accuracy, then save your changes, download, print, or share the completed form as necessary.

Complete your documents online today to enhance your workflow and ensure compliance.