Get Siu Release Of Information Form 2021-2025

Filling out the SIU Release of Information Form online can be a straightforward process with clear guidance. This step-by-step guide will help you navigate through each section of the form, ensuring that you submit all necessary information accurately and efficiently.

Follow the steps to complete the form effectively

1. Click the ‘Get Form’ button to access the SIU Release of Information Form and open it in your preferred document editor.
2. Begin by filling in the 'Patient Information' section with your full name, Dawg Tag number, local phone number, and date of birth.
3. In the authorization section, indicate whether you wish to release, obtain, or exchange protected health information by marking the corresponding checkbox.
4. Specify the agency, facility, or person from whom you are releasing or to whom you are requesting information. Provide their address, city, state, zip code, phone number, and fax number if applicable.
5. If applicable, check the intra-organizational use options, noting the specific departments involved in the record exchange.
6. In the 'Records to Be Released' section, check all relevant categories, such as psychiatric treatment, billing records, and laboratory results. Initial next to items where initials are required.
7. If you wish to exclude any sensitive information, mark the appropriate categories in the sensitive information section and initial next to them.
8. Indicate the purpose of the release by selecting from the provided options, such as patient request, insurance, or continuing treatment.
9. Fill out the date range for the records you wish to release, providing both the starting and ending dates.
10. Choose the format in which you would like to receive the information—electronic, mail, verbal, or paper—and provide any necessary details, such as an email address for electronic requests.
11. Specify the expiration date for your authorization, ensuring that it is filled in completely.
12. Review your rights related to this authorization and acknowledge by signing and dating the form. If someone other than the patient is signing, please indicate their relationship and authority.
13. Have a witness sign the form if required and record their title and the date of signing.
14. Once all fields have been completed, save your changes and select your preferred option to download, print, or share the completed form.

Complete the SIU Release of Information Form online today to ensure your records are handled appropriately.