Get Release Of Information Authorization Form (english) - Legacy ...

Filling out the Release Of Information Authorization Form is an important step in managing your health records. This guide will provide you with clear and supportive instructions to ensure that you complete the form accurately and efficiently, even if you have little legal experience.

Follow the steps to fill out the form online easily.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. Enter the date of birth in the designated field as this identifies the patient and is crucial for processing the request.
3. Fill in the patient’s name, ensuring to use their full legal name as it appears on identification documents.
4. If you are not the patient, specify your relationship to the patient in the provided field.
5. If a person is requesting the information, input their name in the 'Person Requesting' field.
6. Select the type of identification used and provide the corresponding identification number.
7. Enter the phone number to ensure clear communication concerning the authorization process.
8. Indicate your authorization by specifying whether you authorize Legacy Community Health to receive or send records.
9. Provide the name and address of the person or organization to which records are to be sent or received.
10. Fill in the phone number, email address, and any necessary fax numbers for communication.
11. Specify the date range of the records you wish to request to ensure you receive the correct information.
12. Choose the type of information to be disclosed, selecting the appropriate boxes for your needs.
13. Indicate the purpose of disclosure in the required field; this helps clarify the reason for your request.
14. Review the sensitive information notice and ensure you understand the implications of releasing your information.
15. Sign the form either electronically if submitting online or prepare to print it for mailing or faxing.
16. After completing the form, save your changes, then opt to download, print, or share the document as required.

Complete your Release Of Information Authorization Form online today to manage your health records effectively.