Get This Form Is To Be Filled Out By A Customer If There Is A Request To Release The Customers

This guide provides clear instructions for filling out the form required to release a customer’s protected health information (PHI). By following these steps, you can ensure that your request is processed efficiently and accurately.

Follow the steps to complete the form online effectively.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in Part A with your customer information, including your last name, first name, street address, daytime and cell phone numbers, subscriber number, middle initial, date of birth, state, ZIP code, and group number.
3. In Part B, identify the person or company authorized to receive your information. Check the relevant boxes and provide their names as required.
4. In Part C, specify what information can be released. You may choose to allow all information or only limited information. For limited information, check the appropriate boxes to indicate which types of information can be released.
5. If applicable, check any sensitive health information you authorize to be disclosed. Make sure to read the confidentiality information carefully.
6. In Part D, state the purpose of the information release by selecting one of the options provided or describing a different reason in the space available.
7. In Part E, indicate the expiration date of your approval by selecting one of the provided options.
8. In Part F, choose the format in which you want to receive your information and provide any additional necessary details, such as mailing or email addresses.
9. Review the information you have entered in Part G. Sign and date the form to confirm your understanding and approval of the release of your information.
10. If applicable, include any necessary documentation that supports the authority of a legal representative who is signing on your behalf.
11. Once completed, save your changes, download, print, or share the form as needed.

Complete your form online today and ensure your protected health information is released as requested.