Get La 20410-br 2010-2025

The LA 20410-BR is an authorization form for the release of confidential information from Ochsner Medical Center in Baton Rouge. This guide will provide you with clear, step-by-step instructions on how to complete the form online, ensuring that your information is properly authorized for release.

Follow the steps to successfully complete the LA 20410-BR online

1. Press the ‘Get Form’ button to access the form and open it in a suitable online editing tool.
2. Begin by filling in the patient's name and date of birth at the top of the form.
3. Input the address of the patient beneath their date of birth.
4. In the section labeled 'I,', enter the full name of the patient who is authorizing the release of information.
5. Specify the name of the hospital, physician, or facility from which the medical records will be released.
6. Indicate the dates of service for which the information is being released.
7. In the section titled 'Information to be released', check off the items that are to be disclosed such as discharge summaries, consultation reports, and more.
8. Provide the name and address of the entity to whom the information will be released.
9. Indicate the purpose for the release by selecting the appropriate option, such as medical, insurance, or legal.
10. Select the method of delivery for the information, whether by paper or electronically, and provide an email address if necessary.
11. If applicable, provide express authorization for the release of sensitive information related to alcohol and/or drug abuse, HIV testing, or psychiatric treatment.
12. Finally, fill in the signature section at the bottom with the patient's signature or that of an authorized representative, along with their relationship to the patient, address, date signed, and phone number.
13. Once all fields are properly filled, ensure to save your changes, download the document, print it, or share it as needed.

Complete your documents online today for a streamlined experience.