Get Ut Granger Medical Clinic Patient Authorization To Use And Disclose Protected Health Information 2022-2025

The UT Granger Medical Clinic Patient Authorization To Use And Disclose Protected Health Information form is essential for granting permission to share your medical records. This guide provides clear instructions on how to complete the form online, ensuring that you accurately convey your authorization preferences.

Follow the steps to successfully complete your authorization form.

1. Press the ‘Get Form’ button to access the form and open it in your editing tool.
2. Begin filling out the patient information section. You will need to provide your name, account number, street address, date of birth, city, state, primary phone number, alternate phone number, and email address.
3. In the 'Medical Records Released From' section, enter the name of the clinic or provider releasing your medical records, their phone number, street address, city, and state.
4. In the 'Recipient Information - Medical Records Released To' section, fill out the name, street address, city, state, zip code, phone number, fax number, secure email address, and relationship to the patient.
5. Indicate your preferred delivery method for the records by selecting one of the options: in-person, verbal, mail, fax, email, or other.
6. Specify the dates of service for which you are authorizing the disclosure of information.
7. Clearly state the purpose of the disclosure in the designated area.
8. Choose the types of information you wish to release by checking the appropriate boxes under 'Release the Following Information.' This includes patient health information and financial records if necessary.
9. Review the consent section indicating that you understand the terms of the authorization, including the validity period and potential charges for the information.
10. Sign and date the form to authorize the release of your information.
11. If applicable, indicate your representative’s authority and provide any required proof of ID to release the medical records.
12. Once all fields are completed, save your changes, and choose to download, print, or share the form as needed.

Complete your UT Granger Medical Clinic Patient Authorization To Use And Disclose Protected Health Information online today.