Notice of Rights Signature Expiration I may inspect or obtain a copy of the health information that I am being asked to allow the use or disclosure of. I may revoke this authorization at any time in writing signed by me or on my behalf and delivered to Cedars-Sinai Medical Center Health Information Department 8700 Beverly Blvd. AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Failure to provide all information may invalidate this authorization Patient Name Date of Birth Address City Last Name K Paper K Electronic K Inspect or Review Medical Record First Name Phone State Zip I authorize Cedars-Sinai to Release / Request Medical Records For the following Continuing Care Purpose Release To K Request From K Person / Organization City / State / Zip Legal Personal Use Based on California Evidence Code State / Federal Laws require specific authorization to release the following types of information Mental Health HIV test results Alcohol / Drug Abuse A separate authorization is requir....
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How to fill out the CS Form 2034 online
The CS Form 2034 is essential for authorizing the use or disclosure of health information. This guide provides a detailed, step-by-step approach for filling out the form online, ensuring users understand each component and requirement.
Follow the steps to complete the CS Form 2034 online.
- Press the ‘Get Form’ button to access the CS Form 2034 and open it in your preferred online document editor.
- In the 'Patient Name' field, fill in the patient's last and first name as required. It is important to ensure accuracy when entering personal information.
- Enter the patient's date of birth in the designated section. This information is necessary for identifying the health records related to the individual.
- Complete the address fields, including the street address, city, state, and zip code, ensuring each component is filled out correctly for delivery purposes.
- Indicate the purpose of the authorization by selecting the appropriate option—'Continuing Care', 'Legal', or 'Personal Use'. This helps clarify why the information is being requested.
- Fill in the 'Release To' or 'Request From' section by providing the name of the person or organization, along with their address and phone number, to whom the medical records will be released or from whom they will be requested.
- Specify the type of health information to be released by checking the appropriate boxes (e.g., 'Discharge Summary', 'Billing Record', etc.) or using the 'Other' option if applicable.
- Review the section regarding fees for copies of medical records, understanding that there may be costs associated with processing the request.
- Indicate the delivery instructions by choosing whether to mail the records directly or to notify the requestor when the records are ready for pickup.
- Sign and date the authorization at the end of the form, ensuring that the signature matches the name provided in the patient section. If applicable, include the relationship to the patient as well.
- Review the entire form for any errors and make corrections if needed. Once satisfied, save your changes, download, or print the completed form for your records.
Complete your authorization form online today to ensure timely processing of your health information needs.
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