Get Ca 99-02-004 2018-2025

The CA 99-02-004 form is an authorization for the use and disclosure of health information. Completing this form accurately is crucial for allowing healthcare providers to manage your protected health information effectively.

Follow the steps to fill out the CA 99-02-004 form online.

1. Click 'Get Form' button to obtain the form and open it in an editor.
2. Provide your personal information in the 'Patient Information' section. Fill in your full name, social security number, medical record number, and date of birth. This basic information is necessary for identification purposes.
3. Indicate your preferred method for receiving the information by checking one of the options: either to have it mailed to you or to pick it up from the designated healthcare facility.
4. Authorize the use or disclosure of your protected health information by checking the appropriate box—whether the information will be disclosed or obtained.
5. Specify the purpose of the disclosure in the provided space. This helps clarify why the information is being shared.
6. In the 'Information to be disclosed' section, check all applicable boxes for the types of health information you are authorizing for release, such as discharge summary, medical records, and more.
7. Record the date(s) of service relevant to the information you are requesting. This helps to narrow down the records you wish to access.
8. If you have highly confidential information, indicate your authorization by initialing the corresponding sections for categories like mental health treatment or HIV test results.
9. Sign and date the form at the bottom as the patient or representative. Provide a phone number and indicate the authority or relationship if signed by a representative.
10. Complete the expiration date section, specifying when the authorization will no longer be valid. If no date is specified, it defaults to six months from the date of signing.
11. Review all the information for accuracy, then save the changes before downloading, printing, or sharing the completed form.

Get started on completing your CA 99-02-004 form online today!