Get Authorization For Release Of Information Form - Danbury Hospital

Filling out the Authorization For Release Of Information Form is an important step in obtaining your medical records. This guide will provide clear instructions to help you easily complete the form online, ensuring that your information is accurately conveyed.

Follow the steps to complete the form online effortlessly.

1. Press the ‘Get Form’ button to access the Authorization For Release Of Information Form and open it in your preferred online editing tool.
2. Begin by filling out the patient information section. Provide your full name, date of birth, and a contact phone number. Ensure all details are accurate.
3. Next, enter your email address, street address, town/city, state, and zip code in the designated fields. These details are crucial for proper communication.
4. In the section labeled 'To:', specify the individual or institution that you are authorizing to receive your information. Provide their full name and complete address.
5. Select the information you wish to receive by checking the corresponding boxes. Options include laboratory/pathology reports, emergency room records, or other specific records. Remember to initial any disclosures related to sensitive information like drug & alcohol abuse or mental health records.
6. In the date(s) of treatment field, provide the relevant treatment dates to specify which records you are requesting.
7. Indicate your preferred format for receiving the information, whether by secure online portal or paper, and indicate any fees if applicable.
8. Specify an expiration date for the authorization, if desired, or it will automatically expire 12 months from the date of signature.
9. Read the authorization statement thoroughly, ensuring you understand your rights regarding the release of information. Then, sign and date the form at the bottom.
10. If applicable, fill in the authorized representative section, including your representative's name and relationship to you if someone else is signing on your behalf.
11. Once completed, ensure all information is correct, save your changes, and then download, print, or share the form as needed.

Take the time to complete your Authorization For Release Of Information Form online and ensure your medical records are accessible.