Get Providence St. Mary Medical Center Authorization For Use Or Disclosure Of Health Information 2020-2025

Filling out the Providence St. Mary Medical Center Authorization For Use Or Disclosure Of Health Information form online is a straightforward process. This guide will walk you through each step, ensuring you understand how to accurately complete and submit the authorization.

Follow the steps to easily complete your authorization form.

1. Begin the process by selecting the ‘Get Form’ button to access the authorization form. This will open the document for you to fill out.
2. Enter the patient's name and date of birth in the designated fields. Ensure that the information is correct as it is essential for the retrieval of health records.
3. Provide the medical record number if available, and any contact numbers such as home and cell phone numbers.
4. Fill in the current address of the patient including the city, state, and zip code.
5. In the section for 'Use and Disclosure of Health Information,' select the option for whom the health records should be released, whether to yourself or a designated facility/person.
6. Specify the delivery method for the records by checking the appropriate boxes: CD, paper, or email.
7. In the 'Information to be Released' section, choose one option indicating which records you want to be disclosed, or specify if you need only certain types of records.
8. If applicable, check and initial any box that pertains to statutorily protected information, such as mental health treatment or HIV test results.
9. State the purpose for the request by selecting one of the predefined options or writing your own explanation.
10. In the expiration section, fill out the date until which this authorization is valid, or note that it will expire 6 months after signing if no date is provided.
11. Review your entries carefully for accuracy. Once confirmed, sign and date the document, ensuring that if someone else is signing on behalf of the patient, their relationship to the patient is clearly stated.
12. Finally, save your changes, and download, print, or share the completed form as needed.

Complete your Providence St. Mary Medical Center Authorization For Use Or Disclosure Of Health Information online today for efficient management of your health information.