Get Des Moines University Clinic Authorization For Release Of Medical Information 2013

This guide will assist you in completing the Des Moines University Clinic Authorization For Release Of Medical Information form online. By following these steps, you can ensure that your health information is shared with the appropriate individuals in a clear and organized manner.

Follow the steps to complete your authorization form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name in the 'Print Patient Name' section. This confirms that the authorization is for your health information.
3. Next, fill in your date of birth in the 'Date of Birth' field to verify your identity.
4. Provide your complete address including street, city, state, and zip code in the designated sections. This helps in identifying your records.
5. List the names of the family members or friends you authorize to discuss your health and financial information under 'List the family member(s) / friend(s)'. For each person, include their phone number and your relationship with them.
6. In the 'SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION' section, check any applicable boxes relating to mental health, HIV-related information, or substance abuse treatment. Ensure to understand that any unchecked item will not be discussed.
7. Identify any conditions or issues you do not want discussed with the individuals listed on this form in the 'The following condition(s) / issue(s), listed below, will not be discussed' section.
8. Sign and date the form in the designated areas to confirm your authorization. If you are a legal representative, make sure to indicate that as well.
9. Upon completing the form, save your changes. You may also download it, print it for your records, or share it as needed.

Complete your documentation online today to ensure your health information is shared appropriately.