Get Interactive Health Clinic Authorization To Release Confidential Health Information

This guide aims to assist users in completing the Interactive Health Clinic Authorization To Release Confidential Health Information form online. The process is designed to ensure a smooth and secure handling of your confidential health information.

Follow the steps to accurately fill out the authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by filling out the section requesting the name of the facility or doctor you are authorizing to release your health information. Complete the 'Facility/Doctor’s Name' field with the correct name.
3. Next, provide the full address of the authorized facility or doctor, including city, state, and zip code in their respective fields.
4. Enter the phone number and fax number of the facility or doctor to ensure they can be contacted for any necessary communications.
5. Select the types of information you wish to have released. You can choose 'Complete Chart Record', 'Chart Notes', 'Labs/Reports', 'Billing Records', or any other relevant information. Be specific if necessary.
6. Indicate the name and date of birth of the individual whose health records are being released in the respective fields.
7. Fill in the Social Security number and daytime phone number of the individual. If applicable, include the extension for the phone number.
8. Respond to whether you are authorizing the release of your own records by selecting 'Yes' or 'No'. If 'No', specify your relationship to the patient.
9. In the section for the recipient of the information, you can choose to send the information to yourself or another facility/doctor. Ensure to provide their name and address as needed.
10. Select the purpose for releasing the health information, such as 'Adjunctive/Concurrent Care' or 'Transfer of Care'. You may also specify other reasons in the provided field.
11. Review the section indicating that the authorization is valid for 90 days unless revoked. Understand your rights and the implications of this authorization.
12. If you wish to exclude certain types of information from the authorization, check the appropriate boxes.
13. Sign and date the form, either as the patient or as a representative/guardian, if applicable. Ensure all fields are completed before proceeding.
14. Finally, you can save changes, download, print, or share the completed authorization form as needed.

Complete the authorization form online today to manage your health information securely.