Get Page 1 Of 8 Authorization For Release Of Health ... - Northwell Health

This guide provides a clear and informative walkthrough for completing the Page 1 of the Authorization For Release Of Health Information from Northwell Health. Ensuring the correct submission of this form is crucial for the authorized release of your health information.

Follow the steps to complete the authorization form effectively.

1. Begin by selecting the ‘Get Form’ button to initiate the process of obtaining the form and open it in your preferred online editor.
2. In the section labeled 'Patient Name (Print)', clearly print the full name of the patient as it appears on official documents to ensure accurate identification.
3. Enter the patient's date of birth in the format prescribed on the form. This information is crucial for verifying the identity of the patient.
4. Provide the patient's address and telephone number to facilitate communication regarding the release of health information.
5. Indicate if the health information being requested includes sensitive information related to alcohol and drug abuse, mental health treatment, or HIV-related information by initialing the appropriate line in Item 8(a).
6. Complete the fields requesting the name and address of the healthcare provider releasing the information, including the ordering physician's name if relevant.
7. Select the method of receiving the information (Mail, Fax, or Pick-Up) as described in the available options.
8. Specify the details about the information to be released in Item 8, choosing from the options provided or specifying other information as necessary.
9. Fill out the reason for the release of information in Item 9, selecting or noting the appropriate scenario.
10. Enter the date or event that will serve as the expiration for this authorization in Item 10.
11. Complete the printed name and signature of the person signing the form in Item 11, ensuring all signatures are dated.
12. If applicable, fill in the authority of the person signing on behalf of the patient, providing the relationship to the patient for clarity.
13. Once all sections are completed, review the form for accuracy before opting to save the changes, download, print, or share as needed.

Complete your Authorization For Release Of Health Information form online today to ensure the timely release of your health details.