Get Hipaa Release Form - Saltzer Medical Group

Filling out the HIPAA Release Form is a vital step in authorizing the use or disclosure of your protected health information. This guide provides clear and detailed instructions to assist you in completing the form online effectively.

Follow the steps to complete the form with confidence.

1. Click ‘Get Form’ button to obtain the HIPAA Release Form and open it in your preferred editor.
2. Begin by entering the patient’s name in the designated field. This ensures that the authorization pertains to the correct individual.
3. Fill in the patient’s phone number and date of birth. Accurate contact information is crucial for facilitating communication regarding the health information.
4. Provide the full address of the patient. This information is required for proper identification and correspondence.
5. Indicate where the health information is to be obtained from by checking the appropriate options. You may select either 'Request for Medical Information' or 'Authorization to Release Medical Information'.
6. Specify the recipient of the health information by filling out the business name and the doctor’s name if applicable.
7. Complete the send-to address with the recipient's full address, including city, state, and zip code.
8. Note the purpose of release by selecting the appropriate box that describes your reason.
9. Select the specific information you wish to be used or disclosed. Options include complete health records, lab results, consultation reports, and more.
10. If necessary, indicate any specific date(s) of service related to the request.
11. Review any exclusions listed in the form, recognizing that certain types of information may not be disclosed.
12. Choose your preferred method of receiving the records by checking the boxes for pick-up, mail, fax, or email.
13. Print or type the name of the patient and provide their signature in the designated area, along with the date.
14. If applicable, the patient representative should sign and indicate their relationship or authority to act on behalf of the patient.
15. Finally, save the completed form, and choose to download, print, or share it as necessary.

Complete your HIPAA Release Form online today to manage your health information safely.