Get Releaseforms Northshore Org

Filling out the Releaseforms Northshore Org allows you to authorize the disclosure of your confidential medical information. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the online form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your personal information in the designated fields. Start with your full name, date of birth, street address, city, state, zip code, and phone number.
3. In the section labeled 'I AUTHORIZE NORTHSHORE UNIVERSITY HEALTHSYSTEM TO RELEASE TO:', provide the name of the individual or organization receiving the information. If it's an individual, describe their relationship to you.
4. Complete the address fields for the recipient, including street address, city, state, zip code, fax number (if applicable), and phone number.
5. Indicate your preference for how records are sent by checking the appropriate box: Disc (CD), Paper, or Secure Email. If you choose Secure Email, provide the email address.
6. Select the types of records you wish to release by checking the boxes next to the relevant items, such as hospital records, lab test results, and outpatient therapy notes.
7. If you need to release sensitive information, initial the specific areas to release, like psychiatric records or drug/alcohol records.
8. Provide the approximate dates of service relevant to the records being requested.
9. Specify the purpose or need for the information in the designated area.
10. Sign and date the form where indicated, either as the patient or an authorized representative. If signed by a representative, include their relationship to the patient.
11. If applicable, a witness should sign and date the form.
12. Review the notice to patient section to understand the validity of the authorization and your rights regarding the disclosure of information.
13. Finally, save your changes, download, print, or share the completed form as needed.

Complete your documents online today to ensure a smooth and efficient processing of your request.