Get Planned Parenthood Authorization Form For Release Of Health Information 2013-2025

Filling out the Planned Parenthood Authorization Form for Release of Health Information online is a straightforward process that helps ensure your health information is shared according to your wishes. This guide will walk you through each section of the form to facilitate a smooth completion.

Follow the steps to fill out the Planned Parenthood authorization form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering your full name in the designated fields for 'Patient Name.' Include your last name, first name, middle initial, and, if applicable, your maiden or other names.
3. Fill in your date of birth by selecting the month, day, and year.
4. Provide your Social Security number in the specified format, ensuring that you enter it accurately.
5. Input your medical record number in the corresponding section.
6. Indicate whether you are authorizing Planned Parenthood to release your health information to a specific individual or organization, or to law enforcement by selecting the appropriate option.
7. Complete the fields for the name and address of the person, facility, or agency to whom the information should be sent, along with their phone number and fax number, if applicable.
8. If applicable, check the box for your doctor or clinic and enter their name, address, phone number, and fax number.
9. Select the Planned Parenthood health center you wish to send your information to by checking the appropriate box.
10. Specify the health information you want to be released by checking the relevant boxes, such as medical records, lab reports, or mental health information.
11. Indicate the purpose of this authorization by checking the relevant box or providing additional information.
12. Acknowledge that the authorization will expire in one year from the date you sign it, and that you may revoke this authorization in writing if needed.
13. Sign and date the form. If you are signing on behalf of a patient, include your title and relationship to the patient.
14. Review the completed form for accuracy, then save your changes. You can download, print, or share the form as necessary.

Complete your documents online today to ensure your health information is managed efficiently.