Get Authorization To Release Medical Information - Emory Healthcare - Emoryhealthcare

This guide provides clear, step-by-step instructions for completing the Authorization To Release Medical Information form for Emory Healthcare. By following these instructions, users can efficiently provide the necessary information to authorize the release of their medical records.

Follow the steps to successfully complete the authorization form.

1. Use the 'Get Form' button to access the Authorization To Release Medical Information form. Ensure you open the document in a suitable editor to fill out the details.
2. Begin by filling out your medical record number at the top of the form for internal purposes. This helps the healthcare provider identify your records.
3. Fill in your personal information, including your name, last four digits of your Social Security Number, previous name (if applicable), address, city, state, zip code, date of birth, and both home and work phone numbers.
4. Provide your email address for any future communications regarding your request.
5. In the section labeled 'Emory Healthcare Facility/Facilities,' select one or more facilities from which you authorize the release of your health information by checking the respective boxes.
6. Next, identify the receiving party by filling in their name, address, city, state, zip code, telephone number, and fax number, if applicable.
7. Describe the health information you wish to disclose by selecting either 'Complete medical record' or 'Partial Medical Record'. If partial, specify which documents you want to obtain.
8. Indicate the purpose for the release of information by selecting one option, such as 'At my request', or specify another purpose.
9. Fill in the expiration date of the authorization, or note that it will expire 90 days after signing if no date is specified.
10. Acknowledge your right to revoke this authorization at any time by reviewing the information regarding how to do so.
11. Read the sections on re-disclosure, fees, refusal to authorize use, and release and waiver to ensure you understand the implications of your authorization.
12. Sign and date the form, providing your printed name and a description of your authority to act on behalf of the patient, if applicable.
13. Ensure a copy of the completed form is provided to you and that one copy is placed in your medical records. Save, download, or print the completed form for your records or further submission.

Complete your documents online to ensure swift and secure processing of your medical information requests.