Get 18003671500

Filling out the 18003671500 form online can be a straightforward process. This guide aims to assist users in understanding the structure and requirements of the form, ensuring a smooth completion experience.

Follow the steps to successfully complete the 18003671500 form.

1. Click ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering the full name of the patient in the designated field. Ensure that the name is spelled correctly, as it will be used for identification purposes.
3. Fill in the street address of the patient, followed by the city, state, and zip code. Make sure all details are accurate to avoid delivery issues.
4. Include a contact phone number for the patient, ensuring it is a number that can be easily reached if further information is needed.
5. If the patient is under 18 years old, the parent or guardian must provide their name in the designated section.
6. Specify the service dates for the medical information request. It is essential to indicate a clear timeframe to ensure the correct records are gathered.
7. Check the boxes corresponding to the types of medical information you authorize for release. Options may include pathology reports, progress notes, and radiology reports, among others.
8. Indicate if you authorize the release of sensitive information related to AIDS or human immunodeficiency virus (HIV) infection, psychiatric care, or substance abuse treatment, if applicable.
9. Provide the name and address of the individual or organization receiving the medical records. This information is critical for ensuring the proper delivery of documents.
10. Select the reason for the disclosure of information, such as referral to a specialist or legal investigation. If none of the provided options apply, specify the purpose in the space provided.
11. Sign and date the authorization, ensuring it is completed. The authorization is valid for 12 months from the date of signing, so be mindful of this timeframe.
12. After reviewing the form for accuracy, you can save changes, then choose to download, print, or share the completed form as needed.

Start filling out your documents online today to ensure timely processing!