Get Authorization For The Release Of Protected Health Information-veritrust - Veritrust

Filling out the Authorization for the Release of Protected Health Information (PHI) is a crucial step in securing your medical records. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently, ensuring your sensitive information is managed responsibly.

Follow the steps to complete your authorization form:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the patient’s name, including any previous names used for identification.
3. Enter the requestor's name clearly. This is the person or entity requesting the information.
4. Provide the driver's license or government ID number and indicate the state of issuance. Remember to include a photocopy of your ID with the authorization.
5. Complete your address by including the street address, city, state, and zip code.
6. Fill in your date of birth and either your patient number or Social Security number for additional identification.
7. Select the purpose for the information request by checking the appropriate box, such as for continuing medical care or personal use.
8. Clearly identify the source of your medical records by entering the name of the medical practice that holds your records.
9. Choose whether you want the complete medical record or only records from a specific date range by checking the appropriate box.
10. Fill out where the released records should be sent, including the address, email, and phone number.
11. If applicable, specify any documents you do not want disclosed. Remember, you do not have to authorize the release of AIDS/HIV-related information.
12. Indicate the expiration of the authorization, defaulting to 180 days unless a lesser period is noted.
13. Read the provisions regarding revocation and understanding of the privacy laws to ensure you are informed.
14. Finally, sign the form, include the date, print your name, and state your relationship to the patient if you are not the patient themselves.
15. Once all sections are complete, save your changes, download or print the form as needed, or share it according to your requirements.

Take control of your health information today — complete your authorization form online.