Get Cleveland Clinic Florida Authorization To Use And Disclose Protected Health Information Form

This guide will assist you in completing the Cleveland Clinic Florida Authorization To Use And Disclose Protected Health Information Form online. Whether you are familiar with such forms or not, this step-by-step approach aims to make the process simple and clear.

Follow the steps to fill out the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in your chosen editor.
2. Begin by entering your personal information. This includes your full name (last, first, middle), home address, date of birth, home telephone number, and Social Security number.
3. In the section labeled 'Specify Information to be Disclosed', check the boxes next to the relevant categories of protected health information (PHI) that you consent to be shared.
4. Indicate the purpose for the disclosure by checking the appropriate options under the 'Purpose or use of Disclosure' section. If none of the listed options are suitable, you may specify the purpose.
5. Provide the dates of service for which you are requesting the information.
6. If applicable, check any boxes that represent highly confidential information you authorize to be disclosed. Sign next to each category you select.
7. Complete the 'RECIPIENT' section by writing the name and address of the person or organization that will receive your health information.
8. In the 'TERM' section, choose the validity period of your authorization by selecting one of the provided options.
9. Fill out the 'PURPOSE' section with a brief statement outlining the specific intent of the information disclosure.
10. Sign and date the form at the bottom. If the patient is a minor or unable to sign, a personal representative must sign and describe their authority.
11. Once all fields are completed, you may save your changes, download the form for your records, print it if necessary, or share it with the designated recipient.

Complete your forms online today to ensure your health information is shared as needed.