Get Authorization For Use Or Disclosure - Chi Franciscan ...

Completing the AUTHORIZATION FOR USE OR DISCLOSURE form is an essential step in managing your protected health information. This guide provides clear, step-by-step instructions to help you easily navigate the form online, ensuring that your information is disclosed securely and appropriately.

Follow the steps to fill out the authorization form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the patient's name and the last four digits of their Social Security number. Additionally, provide the patient's date of birth to confirm their identity.
3. Select the originating facility from which you wish to request information. This could include options like St. Joseph Medical Center or Franciscan Medical Group. If other facilities are involved, ensure to specify those as well.
4. Identify the purpose of the disclosure by checking the appropriate box, such as 'Attorney,' 'Insurance,' or 'Personal.' This clarifies why you are requesting the information.
5. Indicate the range of dates for which you are requesting records. You can choose options like 'Most recent two years' or specify exact dates. This ensures you receive the relevant information.
6. Select the types of information to be released. Options include clinic notes, lab reports, or billing records, among others. Choose all that apply to ensure comprehensive coverage of your health information.
7. Complete the section to specify the organization or person to whom the information should be released, including their address and phone number if applicable.
8. If you are requesting a copy of your own records, specify how you would like to receive the information, whether by paper, CD, or pick-up.
9. Authorize someone to pick up your records if necessary by providing their name in the designated space.
10. Review the additional authorizations concerning sensitive health information. If you do not wish to release certain types of information, check the corresponding boxes.
11. Review the expiration section to ensure you understand when this authorization will expire. Fill in the date if needed.
12. Sign and date the form at the bottom to confirm your authorization. If someone else is signing on behalf of the patient, provide their relationship and authority.
13. Upon completing the form, save your changes. Download, print, or share the authorization form as needed.

Complete your AUTHORIZATION FOR USE OR DISCLOSURE form online today to manage your health information securely.