Get Concord Ob/gyn Authorization For Use Or Disclosure Of Protected Health Information 59 Ornac Suite 1

Filling out the Concord OB/GYN Authorization for Use or Disclosure of Protected Health Information is essential for managing your health records. This guide provides a clear process to complete the form online, ensuring that your sensitive information is handled securely and efficiently.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin by entering your personal information. Fill in your name, date of birth, telephone number, and address in the designated fields.
3. Select your records release option. Choose 'Option 1' if you want to release records to another physician's office or 'Option 2' if you prefer to receive records yourself or have them sent to someone else.
4. If you chose 'Option 2', provide the name and address of the recipient or organization. Fill in all relevant details including street address, city/state/ZIP, telephone, and fax numbers.
5. Indicate whether you want to release records for all dates by initialing in the specified area or provide specific treatment dates if different.
6. Check the boxes for the types of medical information you want to be released, such as complete records, lab reports, pathology reports, etc.
7. If you wish to include HIV screening results, initial the appropriate area to provide consent for the sensitive information to be included.
8. Specify the purpose of the records release by selecting from options provided or writing another reason in the space available.
9. Review the authorization section where you confirm your consent for the release of information, noting the confidentiality limitations regarding the recipient.
10. Sign and date the form. If you are signing on behalf of a minor, include the signature of a parent or legal guardian as required.
11. Once all sections are completed, save your changes, then download, print, or share the form as needed.

Complete your documents online to ensure easy management of your health information.