Get Binghamton Health Forms

Filling out the Binghamton Health Forms online is a straightforward process designed to facilitate the authorization for release of protected health information. This guide provides clear and concise steps to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully complete the Binghamton Health Forms online.

1. Click the 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering your patient name, date of birth, and B-number in the designated fields. Please print clearly to avoid any issues with legibility.
3. If applicable, fill in your former or maiden name, the year you entered Binghamton University, and the year you left.
4. In the home address section, provide your current residential address. Make sure all details are accurate, including street address, city, state, and zip code.
5. Next, enter your email address and phone or cell number. This information ensures that the health services can contact you if needed.
6. Identify the person or entity who will be receiving your health information by filling in their name and relationship to you. Also, include their address and contact details.
7. In the section regarding the information to be released, specify the types of information you wish to disclose, including immunizations, lab/x-ray results, and any other relevant details. Make sure to include the dates related to this request.
8. Sign and date the authorization at the bottom of the form. Remember, this signature indicates your consent for the release of your health information.
9. Once completed, you can save the changes made to the form. You may choose to download, print, or share the form directly from the editor.

Complete your health forms online today to ensure timely processing of your health information requests.