Get Authorization To Release Phi 02-29-2016

Filling out the Authorization To Release PHI form is an important step in managing your protected health information. This guide will provide clear instructions for completing the form online, ensuring that you can do so with confidence and ease.

Follow the steps to successfully complete the form

1. Press the ‘Get Form’ button to obtain the Authorization To Release PHI 02-29-2016 form and open it in your chosen editor.
2. In the first section, enter your client name in the designated space provided. This should be your full legal name.
3. Next, you will authorize Guiding Change Psychotherapy LLC by confirming their name and phone number, which are already pre-filled for your convenience.
4. Fill in your date of birth in the appropriate field to further identify yourself.
5. Input the physical address of Guiding Change Psychotherapy LLC. This is typically pre-filled but should be verified for accuracy.
6. Indicate whether you would like to release your information to or obtain information from another office or individual by circling the appropriate option.
7. Provide the name, address, phone number, and fax number of the office or individual you wish to disclose information to or obtain it from.
8. In the section titled 'Please check the information to be disclosed', review the items listed and initial next to each type of information you wish to include in the disclosure.
9. Select the purpose of this disclosure by checking all applicable options in the 'Purpose of this disclosure' section.
10. Specify an expiration date for the authorization to ensure it does not extend beyond your intended timeframe. If no date is provided, it will expire in one year.
11. Read through the disclosure information carefully, ensuring you understand the implications of what you are authorizing.
12. Sign and date the form in the spaces provided to confirm your authorization.
13. If applicable, a witness should also sign and date the form on the designated lines.
14. Once completed, you can save the form, download it for your records, print it for physical submission, or share it as needed.

Start managing your protected health information today by completing the Authorization To Release PHI form online.