Get Omh 11 Form

The Omh 11 form is essential for authorizing the release of protected health information within the Office of Mental Health framework. Completing this form accurately is significant for ensuring your information is handled appropriately according to your preferences.

Follow the steps to complete the Omh 11 form online

1. Click ‘Get Form’ button to obtain the form and open it in your digital editor.
2. Begin by entering the patient's name in the designated fields for Last, First, and Middle Initial.
3. Fill in the ‘C’ number as specified, ensuring accuracy.
4. Next, input the patient’s date of birth, maintaining the correct format to avoid errors.
5. Specify the facility name and unit/ward/residence number where applicable.
6. In Part 1, clearly describe the information that is to be used or disclosed, providing precise details.
7. Detail the purpose for which the information is being requested using the provided sections for clarity.
8. Indicate the name, address, and title of the person or organization disclosing the information.
9. Fill out the information for the recipient—specifying the person, organization, or facility to which this disclosure is intended.
10. Review your entries for accuracy before providing signatures. Ensure that the patient or their personal representative signs the authorization.
11. If applicable, complete the section concerning revocation of authorization, ensuring you follow the format provided.
12. Finally, save your changes. You may download, print, or share the completed form as needed.

Complete your documents online today for a seamless experience.