Get Multicare Authorization To Use And Disclose Protected Health Information 2017-2025

Completing the MultiCare Authorization To Use And Disclose Protected Health Information is essential for managing your health information effectively. This guide will provide you with clear and supportive instructions on how to fill out this form online, ensuring that all necessary details are included for a valid authorization.

Follow the steps to complete your authorization form accurately.

1. Click ‘Get Form’ button to access the MultiCare Authorization To Use And Disclose Protected Health Information and open it in the editor.
2. Provide the patient’s name, address, date of birth, city, state, zip code, and telephone number in the designated fields. Ensure that all personal information is accurate and complete.
3. Enter the medical record number and email address, if applicable. This information helps in identifying the correct health records.
4. In the section titled 'I authorize the use and disclosure of health information about me as described below,' complete the information for the facility authorized to release health information. Fill in the name, address, city, state, zip code, and telephone number of the facility.
5. Identify the agency or individual(s) authorized to receive health information and provide their respective details, including address and contact information.
6. Specify the health information that may be used or disclosed by selecting the relevant types of records such as progress notes, lab results, or entire medical records. If there are additional types of information, indicate them in the 'Other' section.
7. If applicable, indicate any sensitive information that may be disclosed, ensuring you check the appropriate boxes, which may include alcohol abuse or communicable diseases.
8. Provide the periods of healthcare for which this authorization applies by entering the start and end dates along with any associated account numbers.
9. Fill in the purpose for the release of information. Choose from options such as treatment, research, or billing. If it is for another purpose, please specify.
10. Sign the document in the 'Patient’s Signature or Legal Representative' section. Ensure the date and time of signing are correctly recorded, and specify your relationship to the patient if you are signing on their behalf.
11. If applicable, have a witness and an interpreter sign where indicated, making sure to include the date and time.
12. Finally, review the completed form for accuracy. After confirming that all fields are filled out, you can save the changes, download, print, or share the completed authorization form.

Complete your MultiCare Authorization To Use And Disclose Protected Health Information online today for easier management of your health information.