Get Release Of Information Form - Rebound

Filling out the Release Of Information Form - Rebound is a crucial step in authorizing the release of your health records. This guide will walk you through the process in a clear and supportive manner, ensuring that you understand each section of the form.

Follow the steps to complete the form effectively

1. Click the ‘Get Form’ button to access the Release Of Information Form - Rebound. Opening this form online allows you to input information at your convenience.
2. Begin by filling in your personal information in the designated fields, including your full name, date of birth, phone number, and email address if enrolled in the portal.
3. In the authorization section, print your name to confirm your consent for Northwest Surgical Specialists, P.C. to release your health information.
4. Specify the purpose for the information release by selecting one of the options provided, such as continuation of care or personal use.
5. Indicate the preferred method for receiving your records, choosing from options like mail, fax, or electronically (ensure you are enrolled in the patient portal).
6. Complete the section to identify the recipient of your health records, including their name, address, and relationship to you.
7. Choose which specific health information to release by checking the applicable boxes, indicating whether you are authorizing chart notes, diagnostic images, or specific notes.
8. Set an expiration date for this authorization, or if left blank, understand that it will expire 90 days from the date signed.
9. Review the section regarding your rights, including the ability to revoke the authorization, and provide your signature and the date.
10. If signing on behalf of the patient, provide your printed name, authority, and relevant details regarding your relationship to the patient.
11. Designate a witness if required and ensure that a verified photo ID is attached to this form.
12. Conclude by saving any changes made to the form, and then choose to download, print, or share the completed Release Of Information Form as needed.

Complete the Release Of Information Form - Rebound online today to ensure your health records are shared promptly.