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Completing the Authorization to Use or Disclose Health Information form is a crucial step in managing your medical records. This guide will provide you with step-by-step instructions to ensure you accurately fill out the form online with confidence.

Follow the steps to effectively complete the authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Read the entire document carefully to understand the requirements. Start completing the form by filling in your personal details: Patient Name, Date of Birth (DOB), Last 4 digits of your Social Security Number (SSN), Address, City, State/Zip, Email Address, Phone, and Alternate Phone.
3. Indicate who is authorized to release your health information by providing the name and contact details of OSF Saint Francis Medical Center, including their phone number and email address.
4. Specify the visit dates or range of dates for the medical records you are requesting. Clearly outline the dates needed in the provided space.
5. Select from the options regarding what type of information you would like to release. Be sure to check any sensitive information if you choose to include it.
6. Provide the name and address of the individual or organization to which your information should be delivered. Include all necessary contact information.
7. State the purpose for which the disclosure of your information is being made in the allocated space.
8. Choose your delivery preference for the information: via OSF MyChart, email, or postal mail. Make sure to be aware of the estimated turnaround times for each option.
9. Read and acknowledge the terms regarding unauthorized re-disclosure, revocation rights, and the voluntary nature of the disclosure by checking the relevant boxes.
10. Sign and date the form at the designated spaces. If required, have a witness sign to verify your identity. Make sure that all signatures comply with legal requirements.
11. Once completed, save any changes you made, then proceed to download, print, or share the form according to your needs.

Complete your authorization form online today and take control of your health information.