Get Ma Holyoke Medical Center Authorization To Use And Disclose Protected Health Information 2022-2025

Completing the MA Holyoke Medical Center Authorization To Use And Disclose Protected Health Information is an essential step in managing your health records. This guide offers clear, step-by-step instructions to help you accurately fill out the form online.

Follow the steps to seamlessly complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal details in the designated fields. This includes your name, medical record number, date of birth, and phone number.
3. In the section labeled 'Release from Holyoke Medical Center (HMC):', specify the name and address of the individual or organization to whom you are authorizing the release of your health information.
4. Select the information you want to release by checking the appropriate boxes under 'What to Release'. You can choose options such as 'Entire Record' or specify 'the following' if you need only particular documents.
5. Indicate the purpose of the request by selecting the appropriate checkbox, such as 'Continuity of Care', 'Legal', or 'Personal'.
6. For the 'Release to HMC' section, repeat the previous steps by providing the name and address, then specify the information you wish to be sent to HMC.
7. If applicable, initial next to the types of privileged information you authorize to be released, including HIV/AIDS, genetic testing, and substance abuse treatment records.
8. Read through the 'Individual Rights' section to understand your rights regarding this authorization. Make sure you are comfortable with the conditions outlined.
9. Set the expiration date for your authorization. By default, it will expire in one year unless stated otherwise.
10. Finally, sign and date the form. If you are not the person being served, indicate your relationship to them.
11. After completing the form, you can save your changes, download the document, print it, or share it as needed.

Complete your documents online to ensure your health information is managed effectively.