Get University Of Michigan Health System Authorization For Verbal Clinical Communication 2018-2025
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How to fill out the University Of Michigan Health System Authorization For Verbal Clinical Communication online
This guide provides comprehensive instructions for filling out the University Of Michigan Health System Authorization For Verbal Clinical Communication form online. Whether you are the patient or an authorized representative, this step-by-step approach will help ensure all necessary information is completed accurately.
Follow the steps to fill out the form correctly online:
- Press the 'Get Form' button to obtain the form and open it in your preferred online editor.
- Enter the patient's date of birth in the designated field to identify the individual authorizing the communication.
- Fill in the patient’s name as it appears on legal documents. Include any maiden name or alternate known as (AKA) in the provided area.
- Provide the patient's current street address, ensuring that all details are correct for proper identification.
- Input the unique patient medical record number (UMHSMRN) if available, followed by the city, state, and ZIP code of the patient's residence.
- Include a valid telephone number and email address for any required follow-up communication.
- Specify your relationship to the patient if you are filling this out as a legally authorized representative.
- Indicate from which UMHS department or provider you wish to authorize communication.
- List the individual(s), organization(s), or company(ies) with whom clinical information may be shared.
- Choose the specific information to be shared from the options listed, and specify any other information needed in the ‘Other’ section.
- Set the date range for the information release, ensuring it aligns with your needs.
- Select the appropriate purpose for the release of information. You can choose multiple options, if applicable.
- Fill in the expiration date or event for the authorization; if left blank, it will default to six months from your signature date.
- Sign and date the form at the bottom, either as the patient or legally authorized representative. Include the printed name and specify your relationship to the patient.
- Once all sections are completed, save your changes, and then download, print, or share the form as necessary.
Complete your documents online today to ensure effective communication regarding clinical care.
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For more information, contact the UMHS Registration and Insurance Verification office toll-free at 866-452-9896 or locally at 734-936-4990, 7 a.m. to 7 p.m., Monday through Friday, and 8 a.m. to 1 p.m., Saturday.
Fill University Of Michigan Health System Authorization For Verbal Clinical Communication
This authorization is voluntary. Records needed for medical emergencies will be faxed directly to a physician or medical facility. Referring Physicians can now complete the Outpatient Consult Request Form to request an appointment with our specialty clinics. If you decide to join the study, you will be asked to give verbal consent before you can start study-related activities. I grant permission to those persons listed below to receive verbal communication regarding billing related to my care. NAME. PHONE. RELATIONSHIP. PURPOSE: To ensure authorization is on file for current and future sharing of information between those listed in Sections 2 and 3 only. I authorize the person listed above to be involved in verbal discussions regarding my healthcare. Please contact the Release of Information Unit at to determine the documentation that will be required to process your request. We have temporarily revised our family and guest policy due to the coronavirus pandemic. To request a copy of your medical records, download, print and complete the UM Health-West Authorization Form.
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