Get Dh3203-ssg-09-2017 - Authorization To Disclose Confidential Information

The DH3203-SSG-09-2017 form is essential for authorizing the release of confidential medical information. This guide will provide you with clear, step-by-step instructions to help you complete the form online effectively.

Follow the steps to fill out the DH3203-SSG-09-2017 form.

1. Click ‘Get Form’ button to access the DH3203-SSG-09-2017 form, allowing you to open it in your preferred online editor.
2. In the section labeled 'Information may be disclosed by,' enter the name, phone number, and address of the person or facility that holds the confidential information.
3. Next, in the section 'Information may be disclosed to,' provide the name, phone number, and address of the individual or facility to whom you wish to disclose the information.
4. Select the method of disclosure by checking the appropriate options such as 'Pick up at Clinic/Facility,' 'Fax,' or 'Email Address.' If using email, please note the potential risks regarding security.
5. Indicate the specific information to be disclosed by checking the boxes corresponding to your selections, such as 'General Medical Record(s),' 'Consultations,' or 'Diagnostic Test Reports.' Make sure to specify the type of tests if applicable.
6. In the 'I specifically authorize release of information relating to' section, check any applicable boxes related to sensitive information, such as 'HIV test results' or 'Substance Abuse Service Provider Client Records.'
7. Provide the purpose for the disclosure by selecting an option such as 'Continuity of Care' or 'Personal Use.' If you select 'Other,' please specify.
8. Fill in the expiration date for this authorization. If you do not specify a date, the authorization will automatically expire twelve months from the date of signing.
9. Review the statements regarding redisclosure and conditioning. Ensure you understand your rights regarding revocation and that treatment will not be denied if you choose not to sign.
10. Sign the document as the client or legal representative, including the date. Clearly print your name and relationship to the client in the designated spaces.
11. If applicable, a witness can sign the form and provide the date to validate the authorization.
12. Finally, save your changes, and download or print a copy of the completed form for your records. You may also share it as needed.

Complete your documents online today for a smooth and secure process.