Get Ma Dph 5-a 2008-2025

The Massachusetts Department of Public Health 5-A form is an authorization for the release of information, allowing individuals to give permission for their information to be shared with specified persons or organizations. This guide will walk you through each section of the form to ensure you complete it accurately and effectively.

Follow the steps to fill out the MA DPH 5-A form online

1. Press the ‘Get Form’ button to access the MA DPH 5-A form online. This will open the document for you to fill out.
2. In Section I, print your name in the designated field. Next, fill in the name of the person or organization you are authorizing to share your information.
3. Move to Section II, where you will provide details about the health and personal information you wish to share. Be specific and include relevant dates and details.
4. In Section II (B), indicate your permission regarding specific health information by placing your initials next to each applicable category you wish to share, such as HIV information or alcohol treatment details.
5. Proceed to Section III to describe the reason(s) for sharing your information. If you prefer, you can simply state 'at my request.'
6. In Section IV, fill in the name, organization, and address of the person or organization you are permitting to share your information.
7. Next, go to Section V and list the name, organization, and address of the person or organization that will receive your information.
8. In Section VI, specify how long you want this permission to last by indicating a date or event. If you do not specify, the permission will automatically last for one year.
9. Finally, you must sign and date the form in Section V. If the form is being filled out by someone else on your behalf, they should provide their details as required.
10. Once you have completed the form, you can save your changes, download it, print it, or share it as needed.

Complete the MA DPH 5-A form online today to ensure your information is shared appropriately and securely.