Follow the steps to fill out the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your editor.
2. In Part 1, input the consumer's information. Fill in the last name, first name, middle initial, TABS ID number, date of birth, address, and phone number if known.
3. Move to Part II to authorize the disclosure of clinical information. Indicate the organization that will disclose the information by writing their name and address in section A. Additionally, provide the individual's name whose information is being disclosed.
4. For section B, specify the organization receiving the information by entering their name and address. Again, include the individual's name related to this disclosure.
5. Describe the specific information to be disclosed, including relevant dates of service and types of services such as psychological evaluations, individual service plans, and medical assessments.
6. Detail the purpose of the disclosure by checking appropriate boxes like treatment purposes, documentation eligibility, or planning services. You may also provide additional reasons in the space provided.
7. If applicable, complete the section that indicates whether the requester will receive compensation for the disclosed information, selecting 'Yes' or 'No'.
8. Proceed to Part III, where the consumer or their personal representative must sign and date the form. Ensure the print name and relationship of the representative to the individual are properly documented.
9. Lastly, indicate the expiration date of the authorization in the provided space.
10. Once all sections are completed, you can save your changes, download, print, or share the form as needed.

Complete your HIPAA Authorization form online today to ensure your clinical information is shared securely.