Get Authorization Form - Advantagecare Physicians

Filling out the Authorization Form is an important step in managing your protected health information with AdvantageCare Physicians. This guide provides clear, step-by-step instructions to help you navigate the form and ensure your information is properly authorized for disclosure.

Follow the steps to complete the Authorization Form.

1. Press the ‘Get Form’ button to obtain the Authorization Form - AdvantageCare Physicians and open it in your preferred editor.
2. Begin by filling in your personal information in the designated fields. Complete your name, date of birth, address, and telephone number so that AdvantageCare Physicians can easily reach you.
3. Indicate where you would like your protected health information (PHI) to be disclosed by selecting 'Self' or specifying the name and address of the facility or entity. This section is critical, as it dictates who will receive your information.
4. For the second section, specify the facility or entity from which you request your PHI to be disclosed. Provide the necessary contact information, maintaining accuracy to avoid delays in processing.
5. Choose the specific types of PHI you wish to be released from your medical records by checking the appropriate boxes. You may select an abstract/summary, test results only, or specify other types.
6. Provide the dates of service for which you are requesting the records. This helps ensure that only the relevant information is disclosed.
7. Select the format in which you would like to receive the records by choosing between paper format or electronic format. If you select electronic, be sure to include a valid email address for the delivery.
8. Review any sensitive information that may apply to your records and indicate your consent by initialing the relevant boxes. It's essential to consider all sensitive information carefully.
9. Specify the purpose for requesting your information. Choose the appropriate reason from the options provided, or list a different purpose if necessary.
10. Sign and date the authorization form at the bottom, ensuring you provide your printed name and the relationship or authority of the person signing the authorization, if applicable.
11. After completing the form, you can save any changes, download, print, or share the form as needed, ensuring that you keep a copy for your records.

Start completing your Authorization Form online today to manage your health information effectively.