Get Permission To Verbally Discuss Protected Health Information With Family And Friends

Filling out the Permission to Verbally Discuss Protected Health Information form is an important step in ensuring that your healthcare providers can communicate with your chosen family and friends regarding your health. This guide provides user-friendly, step-by-step instructions to help you complete the form online with ease.

Follow the steps to complete the form effectively.

1. Click the 'Get Form' button to access the form and open it in the editor. This allows you to begin the completion process.
2. Enter your full name in the designated field labeled 'Patient name'. This identifies the individual granting permission.
3. Fill in your date of birth in the 'DOB' section. This is crucial for verifying your identity.
4. Provide your street address, city, state, and ZIP code in the respective fields. This information helps locate your records.
5. Include your home and work phone numbers in the appropriate fields so that family or friends can be reached if necessary.
6. If you know your medical record number (MR#), enter it in this field for additional verification; if not, you may leave it blank.
7. Review the sections where you can indicate what information can be shared by checking the appropriate boxes, which may include scheduling information, medical details, behavioral health information, and more.
8. List the names and contact information of the individuals you wish to authorize in the designated areas. Ensure their contact details are accurate.
9. Read and understand the statements regarding your right to revoke permission and the conditions under which your information can be shared.
10. Sign the form in the designated space, indicating your consent for the disclosures outlined. Ensure you date the form as well.
11. If you are signing on behalf of another person, note your relationship and authority to sign in the specified field.
12. Once completed, you can save changes, print the document, or share it as required. Make sure to submit it to the appropriate HealthPartners location as detailed in the form.

Complete your documents online to ensure your privacy preferences are respected.