Get Authorization For Release Of Information - Delr

This guide provides a clear and supportive approach to filling out the AUTHORIZATION FOR RELEASE OF INFORMATION form used by DeBalzo, Elgudin, Levine, Risen LLC (DELR). You will find step-by-step instructions to ensure a smooth online completion process.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to obtain the form and launch it in your online editor.
2. Fill out the patient name and date of birth. Ensure that the details entered are accurate to avoid any issues with information release.
3. Enter the patient's current address and telephone number. This is crucial for proper identification and communication.
4. Provide the social security number of the patient. This helps in confirming the identity of the individual authorized for the release.
5. Identify the provider’s name who is employed by DELR who is authorized to release information.
6. Specify whether the information will be released to, received from, or exchanged with another facility or individual. Clearly state their name and address.
7. Indicate the specific medical information you wish to be disclosed by checking the appropriate boxes. Choose from options such as entire record, clinical notes, psychological testing, etc.
8. State the purpose and need for the information release. Check the applicable reasons, ensuring the rationale aligns with your needs for treatment or legal requirements.
9. Review the statement regarding the confidentiality of the information. Acknowledge your understanding by checking any required boxes.
10. Sign the authorization form. This can be done by the patient, a legal guardian, or another authorized person, along with their printed name and relationship to the patient.
11. Have a witness sign the form as needed. Include their printed name and the date of signing.
12. Finally, save your changes, then download, print, or share the completed form as required to ensure it reaches the relevant entity.

Complete your AUTHORIZATION FOR RELEASE OF INFORMATION - DELR online today and ensure your information is handled efficiently.