Get Download Form - Rothman Institute

Filling out the Download Form from the Rothman Institute is a straightforward process that allows users to authorize the use and disclosure of their protected health information. This guide provides step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to complete the Download Form successfully.

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred document editor.
2. In the first section, provide your name as the patient in the designated fields labeled 'Patient Name (Print: First, Middle, Last)'. Be sure to include all parts of your name.
3. Sign the form as the patient in the field marked 'Patient Signature'. Your signature indicates your authorization for the release of information.
4. If applicable, enter the name and signature of your personal representative in the provided fields. Also, specify their relationship to you in the 'Representative's Relationship to Patient' section.
5. Complete the 'Patient Information' section by filling in your address, date of birth, and phone number, ensuring all information is current and accurate.
6. Select the type of records you are requesting by checking the appropriate box in the 'I am requesting' section. Make sure to provide any relevant details in the spaces provided.
7. Fill in the recipient's information, including their name, address, and contact details in the 'Recipient Information' section to ensure proper delivery.
8. Review the 'Payment and Processing Information' for any applicable fees associated with your request. Include payment details as required.
9. Once all sections are complete, review your form for accuracy. Save any changes made, then proceed to download, print, or share the form as needed.

Complete your Download Form - Rothman Institute online today and ensure efficient handling of your health information.