Get Dhs 4000

This guide provides clear and concise instructions on how to fill out the Dhs 4000 form online. By following these steps, users can ensure that their health information is disclosed correctly and securely.

Follow the steps to complete your Dhs 4000 form online

1. Click ‘Get Form’ button to access the Dhs 4000 form and open it in your preferred editor.
2. Fill in the client name field with the full name of the individual authorizing disclosure of their health information.
3. Enter the client's mailing address. Include street address, city, state, and zip code.
4. Provide the client ID number as assigned by the relevant department.
5. Input the client's date of birth in the required format.
6. Specify the name of the case head, if applicable. This is the individual responsible for the case.
7. In the authorization section, make sure to write the name of the person or personal representative who is granting authorization.
8. Include the name of the provider or plan from which the specific health information will be disclosed.
9. Fill in the recipient's details including name, address, phone number, and fax number where the information will be sent.
10. Outline the specific purpose for the disclosure of health information in the provided space.
11. Indicate the specific information that is authorized to be disclosed. This may include all medical records or specific types of information.
12. Set the expiration date for this authorization. If none is specified, it will last for one year unless revoked.
13. Review the content of the authorization carefully to ensure all provided information is accurate.
14. Sign the form in the designated area, including the date of signing.
15. If applicable, have a personal representative sign and note their relationship or authority.
16. After filling out the form, you may choose to save changes, download, print, or share the document as needed.

Complete your Dhs 4000 form online today to ensure proper disclosure of health information.