Get Omsi 581 Authorization To Release Information - Draft 121514docx

This guide provides a step-by-step approach to filling out the OMSI 581 Authorization To Release Information form online. By following these instructions, users can ensure accurate completion of the form to facilitate the release of health information.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient’s full name in the designated field at the top of the form.
3. Provide the date of birth by filling in the appropriate field.
4. Enter the patient's address, including street, city, state, and zip code in the corresponding sections.
5. Fill in the phone number of the patient in the specified field.
6. Select the preferred delivery method from either Mail or eDelivery (note that eDelivery is for personal requests only).
7. If the health information is needed for a specific doctor’s appointment, indicate the date in the provided section.
8. Specify the individual or organization that is authorized to make the disclosure by filling in their name, address, and phone number.
9. Choose the type of information to be disclosed by checking the appropriate boxes based on the options provided.
10. Indicate the purpose for the release of this information by completing the respective field.
11. Understand and acknowledge the terms of revocation by reading the section carefully.
12. Sign the form by providing the patient's signature and date, also include the name and signature of any authorized representative if applicable.
13. Finally, save the changes, download, print, or share the completed form as needed.

Complete your OMSI 581 Authorization To Release Information form online today!