Get Vcu Health System Authorization To Release Health Care Information Jan 2013 Version

This guide provides step-by-step instructions for completing the VCU Health System Authorization To Release Health Care Information form online. Follow the outlined steps to ensure accurate and efficient submission of your health care information release request.

Follow the steps to complete the form effectively.

1. Click the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Enter the patient’s full name in the designated field to identify the individual whose health care information is being requested.
3. Fill in the date of birth in the format M/D/Y to verify the patient's identity.
4. Provide the patient’s street address, including any apartment number, in the appropriate section.
5. Input the patient’s home or cell phone number to facilitate any further communication.
6. Complete the patient’s work phone number, if applicable, to offer an additional contact method.
7. Specify the name of the individual or organization that the information will be released to or obtained from in the 'Information to Be Released To or Obtained From' section.
8. Fill in the complete street address, city, state, and zip code of the recipient to ensure accurate delivery.
9. Provide the fax number only if the request pertains specifically to continuity of care.
10. Enter the recipient's email address, noting that records will be available via a secure web portal.
11. In the section labeled 'I, _____________ hereby authorize,' write the patient’s full name again to affirm authorization.
12. Indicate the specific health information that should be released, such as discharge summaries, laboratory reports, or any other documents as listed in the form.
13. Select the purpose of the information release by checking appropriate options like treatment, legal purposes, or others as necessary.
14. Record the approximate service dates if known to help contextualize the information being requested.
15. Understand that you have the right to revoke this authorization by delivering a written request to the appropriate party.
16. Make sure to sign and date the form where indicated, ensuring the signature matches the printed name for validation.
17. If signing on behalf of the patient, indicate your legal authority and complete the necessary documentation of your relationship.
18. Finally, review all the entered information for accuracy before saving, downloading, printing, or sharing the completed form.

Complete your documents online to ensure a smooth and efficient process.