Get Tx St. David’s Healthcare Release/disclosure Of Protected Health Information (phi) 2016-2025

Filling out the TX St. David’s HealthCare Release/Disclosure Of Protected Health Information (PHI) form online ensures that your medical records are accessed in compliance with privacy laws. This guide provides step-by-step instructions to help you navigate each section of the form with ease.

Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Fill in Section A: Patient Information. Provide the patient's name, address, birth date, contact numbers, and the last four digits of their social security number (optional). This section is mandatory for all authorizations.
3. In the 'Facility From Which PHI Will Be Released' section, check the box next to St. David's South Austin Medical Center.
4. Fill in the 'Facility/Person To Whom PHI Will Be Released/Disclosed' section with the name, address, and contact numbers of the recipient.
5. Specify the purpose of the disclosure by checking relevant options such as 'Follow Up Care' or 'Personal Use.' If choosing 'Other,' please provide an explanation.
6. Indicate the preferred delivery method by checking either 'Paper Copy' or 'Electronic Media.' If selecting electronic delivery, provide a legible email address.
7. Select the information to be used/disclosed from the available options. Indicate whether the request includes psychotherapy notes, or select other items as needed.
8. Review the statements under the understanding section, noting the rights concerning authorization. Ensure to mark the appropriate consent options.
9. In Section C, provide the signature of the patient or authorized party, along with the date and the printed name. If applicable, include the witness signature and their printed name.
10. Once all sections are completed, save your changes, and download, print, or share the form as needed.

Complete your TX St. David’s HealthCare Release/Disclosure Of Protected Health Information (PHI) form online today to access your medical records efficiently.