Documentation on the above Personal Representative has been obtained. Signature and Title of Agency Representative HIPAA 402P Page 1 of 2 Issued 4/14/03 Revised 09/17/2013 Important Information about Authorization We may need your authorization to use disclose or obtain your health information for some of our services. Authorization to Release or Obtain Health Information including paper oral and electronic information Request Date Name Mailing Address Date of Birth City/State/Zip Medicaid or Social Security I authorize Name Relationship Telephone Number TO RELEASE Information TO OR TO OBTAIN Information FROM Place an X in the box that indicates if the information is being released OR requested* The Purpose of this Authorization is indicated in the box es below. Place an X in the box es that apply. Further Medical Care Personal Legal Investigation or Action Changing Physicians Research related treatment Creating health information for disclosure to a third party. Other Specify I author....
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How to fill out the LA HIPAA 402P online
The LA HIPAA 402P form is an important document used to authorize the release or obtainment of health information. This guide is designed to help you navigate the process of filling out the form online, ensuring clarity and ease in each step.
Follow the steps to accurately complete the form
- Click ‘Get Form’ button to access the form and open it for editing.
- Begin by entering the request date at the top of the form. This helps indicate when the authorization is being made.
- Fill in your name and mailing address. Include your date of birth alongside your city, state, and zip code.
- Provide your Medicaid number or Social Security number in the designated field.
- Identify the person or organization you are authorizing. Write their name and mailing address, along with their city, state, zip code, and relationship to you.
- Select whether you are authorizing the release of information or obtaining information by placing an ‘X’ in the appropriate box.
- Specify the purpose of the authorization by marking the relevant boxes, such as 'further medical care' or 'personal.' You can also specify any other purpose.
- Indicate the specific protected health information you are authorizing for release by checking the boxes for the items you wish to include.
- Complete the section regarding special consent, if applicable, by checking the boxes that relate to sensitive information.
- Provide an expiration date for the authorization and sign the form. If you do not indicate a date, it will expire six months from the signature date.
- Have a witness sign the form if you signed it with an ‘X’ or mark.
- Review all provided information for accuracy, then save your changes, download, print or share the form as needed.
Complete your documents online to ensure a smooth authorization process.
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HIPAA 402P. Issued 03/10 ... P.O. Box 629, Baton Rouge, LA 70821-0629. ... E-mail:...
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