Get Use And Disclosure Of Protected Health Information: Date ... - Mymercymedicalgroup

Filling out the Use and Disclosure of Protected Health Information form is an essential step in managing your health information. This guide provides a clear and supportive approach to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete the form.

1. To begin, click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. In the first section, enter your full name as the patient. Next, fill in your date of birth, any other names you have used, your telephone number, and your complete address including street, city, state, and zip code.
3. Immediately following your information, you will need to specify the facility or provider that you are authorizing. In this case, write 'MMG / A Service of Dignity Health Medical Foundation'.
4. Next, identify the persons or organizations that will receive the information by writing their names. After that, include their complete delivery address.
5. Select your preferred method for delivery of the health information by checking one box from the provided options. These include options for pick-up at the office, mailing to you, mailing to your physician, or electronic copies.
6. If you select electronic delivery, enter a non-work-related email address to receive your health records securely. Ensure that this address is accurate by providing your signature.
7. If applicable, acknowledge special records by checking the appropriate boxes that pertain to your health records. This includes mental health, substance abuse, or other specific records.
8. Indicate the specific types of records you wish to disclose by marking the relevant boxes and specifying any additional details, including the dates of treatment if necessary.
9. State the purpose of the disclosure. You can select 'At the request of the patient or personal representative' or specify another reason.
10. Finally, sign and date the document, and if applicable, include the name of your personal representative and their relationship to you. Verify the identification as necessary.
11. Once you have filled out the form, you can save changes, download, print, or share the document as needed.

Complete your documents online effortlessly to manage your health information today.