Get Consent To Release Information Form - Bair, Peacock, Mcdonald ...

Filling out the Consent To Release Information Form is a crucial step in authorizing the release of your protected health information. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently online.

Follow the steps to fill out the form carefully.

1. Press the ‘Get Form’ button to obtain the form and open it for editing. This will allow you to access the necessary fields for completion.
2. In the 'Patient’s Name' section, enter your full name as it appears on your clinical records. Ensure that you provide accurate details for identification.
3. Fill in your date of birth (DOB) in the designated area to confirm your identity and differentiate between individuals with similar names.
4. Provide your current address and phone number. These details help the practice contact you or confirm your identity.
5. Indicate the dates of service for which you are requesting the information. This helps the recipient know which records pertain to your request.
6. Identify the person authorized to release or obtain your health information by writing their name in the designated space.
7. Select the specific information you wish to release by checking the appropriate boxes next to the options provided (e.g., discharge summary, clinical progress notes, etc.).
8. If applicable, indicate if you want two-way communication between the releasing and receiving parties by checking the corresponding box.
9. Specify the name and address of the individual or entity to whom the information is to be released.
10. Detail the purpose of the release. If uncertain, you may write 'continuity of care' or 'at the request of the individual' to simplify this.
11. Note the expiration date for this authorization. If no specific date is selected, the default will be 60 days.
12. Sign and date the form at the bottom as the patient or legal guardian. If someone else is signing on your behalf, include information about their authority.
13. If required, have a witness sign the form to verify the authenticity of your authorization.
14. Upon completing the form, ensure you save your changes. You can then download, print, or share the completed document as necessary.

Complete your Consent To Release Information Form online today for timely processing of your health information.