Get Da 5006 2003-2025

The DA 5006 is an important document used for the authorization of medical information disclosure. This guide will provide you with a clear and straightforward process to complete the form online.

Follow the steps to fill out the DA 5006 effectively.

1. Click the ‘Get Form’ button to obtain the DA 5006 and open it in your preferred editor.
2. Fill in the patient data section by entering the patient's name (last, first, middle initial) and date of birth in the format YYYYMMDD.
3. Provide the period of treatment by specifying the start and end dates in the format YYYYMMDD to YYYYMMDD.
4. Enter the social security or identification number of the patient.
5. Indicate the type of treatment by selecting one of the options: outpatient, inpatient, or both.
6. Specify any restrictions on information disclosure, if applicable.
7. Outline the use of medical information such as further medical care, insurance claims, attorney involvement, or disability determination by selecting the relevant options.
8. Provide the name and address of the individual or organization to whom the information should be released.
9. Complete the release authorization section by signing and dating the form. Ensure you include your relationship to the patient if applicable.
10. If available, include an imprint of the patient's identification plate.
11. Finally, review all entered information for accuracy and completeness before saving changes, downloading, printing, or sharing the completed DA 5006.

Complete your documents online today for a hassle-free experience.