Get 1055-18 Authorization Form To Use And Disclose Phi V7.indd

This guide provides comprehensive instructions on how to successfully fill out the 1055-18 Authorization Form To Use And Disclose PHI online. By following these steps, you can efficiently authorize the release of your protected health information while ensuring clarity and compliance.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In section A, enter your member information, including your last name, first name, member ID number, middle initial, birth date, phone number, street address, city, state, and zip code. Ensure that all fields are filled out completely.
3. In section B, indicate the person or entity with whom your PHI will be shared. Check the appropriate box (spouse, domestic partner, adult child, parent, or other) and provide their full name and contact details.
4. In section C, select the type of health information that Healthfirst is authorized to share. You will need to specify the date range for the records and initial next to any sensitive information you permit to be shared.
5. In section D, outline the purpose of this authorization. This could be a specific request or a general statement such as 'at my request'.
6. In section E, provide an expiration date for the authorization or describe an event that will terminate this authorization. Remember that it cannot exceed 24 months from the signing date.
7. Review section F for important information regarding your rights concerning revoking the authorization.
8. In section G, sign the form. If you're acting on behalf of the member, ensure to describe your relationship and provide the necessary documentation.
9. Once all sections are completed, you can save any changes, download a copy for your records, and print or share the form online as needed.

Complete your authorization form online to facilitate the sharing of your health information.