Get Case Management Consent Form And Release Of Medical Information

Completing the Case Management Consent Form And Release Of Medical Information is a crucial step in participating in case management services. This guide will walk you through each section of the form to ensure a smooth and efficient process.

Follow the steps to successfully complete your consent form.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering your personal information. Fill in your full name — last, first, and middle — in the designated fields to accurately identify yourself.
3. Next, provide your date of birth and contract number. This information is necessary for verifying your identity and ensuring the correct association with your case management record.
4. Review the consent statement regarding participation in the case management program. Make sure you understand the outlined services and your rights concerning the consent to be contacted by the case manager.
5. Sign and date the form to give your consent. If needed, include the name and relationship of an authorized representative who may assist you.
6. Proceed to the release of medical information section. Here, carefully check all applicable boxes indicating what specific information you permit to be released.
7. In Section B, indicate permission for the information to be disclosed, selecting all relevant options that apply to your healthcare providers or other agencies.
8. Complete Section C by choosing whether you allow for the disclosure of general medical information, substance abuse treatment information, and mental health information. Remember to be aware of how withdrawal of consent can be managed.
9. Lastly, check to ensure all sections are filled out correctly. Save your changes, download the completed form, and print or share it as necessary.

Complete your Case Management Consent Form And Release Of Medical Information online today to ensure your eligibility for vital services.