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This guide provides comprehensive instructions on how to fill out the authorization for use or disclosure of protected health information form online. Completing this form accurately is crucial for the proper handling of your medical records.

Follow the steps to effectively complete the form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your personal information. Start by entering the patient’s name, date of birth, any other names used, telephone number, and medical record or account number, if applicable.
3. Indicate the facility responsible for the disclosure by selecting 'Mercy San Juan Medical Center'.
4. Specify the persons or organizations authorized to receive your health information. Enter their name and address accurately.
5. Select the type of health information you are authorizing for use or disclosure by checking the appropriate boxes. Include any specific records you wish to release.
6. Clearly state the purpose for the disclosure by choosing from the predefined options or by writing a brief explanation if applicable.
7. Set expiration for the authorization. You may choose a specific date or allow it to expire one year from the date of signing.
8. Read your rights regarding the authorization carefully; this includes your right to revoke the authorization at any time.
9. Sign the form by entering your signature, followed by the date. If applicable, provide the printed name and relationship of the personal representative.
10. Review all entered information to ensure accuracy, then save changes, download, print, or share the completed form as necessary.

Complete your authorization for use or disclosure of protected health information online today.