Get Providence Health Plan Authorization To Disclose Form 2011

The Providence Health Plan Authorization To Disclose Form 2011 allows users to authorize the release of their protected health information. This guide provides a step-by-step approach to filling out this important document online, ensuring clarity and compliance.

Follow the steps to complete the form online with ease.

1. Press the 'Get Form' button to access the form and open it in your digital editor.
2. Fill in the provider’s full name, including title and credentials, followed by their street address, city, state, and zip code.
3. Enter the name of the individual whose health information is being disclosed. Include their first name, middle initial, and last name.
4. Provide the date of birth of the individual in the designated space.
5. Indicate the start date of the Individual and Family Plan health insurance coverage.
6. Select the specific health information required for the disclosure by checking the pertinent boxes listed.
7. If applicable, initial next to the types of sensitive information you authorize for disclosure.
8. Read and acknowledge the rights regarding the authorization, including the right to refuse or revoke the authorization.
9. Fill in the expiration details for the authorization, whether by stating a date or an event.
10. Sign and date the form. If completed by a representative, ensure their relationship to the member is clearly stated and legal documentation is attached if required.
11. Review all filled sections for accuracy before saving your changes, downloading, printing, or sharing the completed document.

Complete your documents online today for a hassle-free experience.