Get Fax Or Email Completed Form To: 888-316-9085 Intake ...

This guide provides a clear and comprehensive approach to completing the Fax Or Email Completed Form To: 888-316-9085 Intake online. Follow these steps to ensure that all necessary information is accurately filled out to facilitate the processing of your request.

Follow the steps to complete the form accurately:

1. Press the ‘Get Form’ button to obtain the Fax Or Email Completed Form. This will allow you to access the document you need.
2. Begin by filling in the Patient Name field at the top of the form. Ensure you use the full legal name of the patient.
3. Next, enter the patient’s address in the designated field. Include street address, city, state, and zip code.
4. Provide a contact phone number where you can be reached, ensuring it is correct.
5. Fill in the patient’s date of birth. This should be in the format of month, day, and year.
6. Enter the medical record number if applicable, as this helps in identifying the patient's file.
7. In the Authorization for Release of Patient Health Information section, indicate the person or institution that holds the health information. Include their full address.
8. Fill in the recipient information for where the health information is being sent. This includes another person or institution's name and address.
9. State the purpose for the information request. This should be a brief description of why you need the health records.
10. In the disclosure section, check all relevant boxes that pertain to the health information that should be included.
11. Specify the records period — from start date to end date — to clearly define the timeframe of the requested documents.
12. If there are specific types of health information you do not want released, ensure to check the appropriate boxes provided.
13. Review the authorization statement carefully, ensuring you understand the details regarding revocation and the validity of the authorization.
14. Sign the form where indicated. If you are signing as a parent or legal guardian, include your signature in the appropriate field.
15. Include the date of signing and your relationship to the patient if required. If a witness is required, ensure that field is also completed.
16. After completing all fields, save your changes, download a copy for your records, and print or share the completed form as necessary.

Complete your documents online today to ensure a smooth process.