Get Print Form 3009 Loma Linda University

Filling out the Print Form 3009 is essential for authorizing the disclosure of your protected health information. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the form online with ease.

1. Press the ‘Get Form’ button to acquire the form and open it in the document editor.
2. Enter your personal details in the 'Patient Identification' section, including your name, birth date, and phone number.
3. Specify from whom you are requesting records by selecting the appropriate clinic, specialty, or physician.
4. Indicate to whom the records should be sent by filling in the 'Send records to' section with the individual's or agency's name, address, city, state, and zip code.
5. Select the type of information to be released. Choose whether the services were rendered as inpatient or outpatient and specify dates of treatment and documentation needed.
6. State the purpose for the disclosure of the records, selecting from options like 'Continued Care' or 'Personal Use'.
7. If applicable, authorize the release of sensitive health information, such as HIV test results, by marking the relevant options.
8. Finalize the form with your signature and the date completed. If a legal representative is signing, ensure their relationship to the patient is noted.
9. After verifying that all information is complete and accurate, save your changes. You can then download, print, or share the form as needed.

Complete your Print Form 3009 online today to ensure smooth processing of your health information.