Get Give Another Person Or Organization Permission To Access Your Health Information

This guide provides clear and step-by-step instructions on how to fill out the Give Another Person Or Organization Permission To Access Your Health Information form online. By completing this form, you empower another individual or organization to access your health information as needed.

Follow the steps to successfully complete the form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out Section 1, which asks for your personal information. Include your name, member ID number, contact information, and date of birth.
3. In Section 2, specify the details of the health information you are authorizing for disclosure. This includes selecting the types of information and the purpose for which this information will be used.
4. Provide the name and contact information of the person or organization to whom you are granting access in the same section.
5. Proceed to Section 3 for the signature. Read the statements regarding your rights and the nature of the authorization. Sign and date the form as the person authorizing the access.
6. If applicable, ensure any necessary documentation verifying legal authority, such as guardianship or power of attorney, is attached.
7. Finally, save your changes, and download or print the completed form. Submit the form as instructed, ensuring you send it to Children's Community Health Plan at the provided address.

Complete your document online today to grant access to your health information.