Get Authorization For Use Or Disclosure Of Information Uab Health

Filling out the Authorization For Use Or Disclosure Of Information UAB Health form is a crucial step in managing your health information. This guide provides clear, step-by-step instructions to ensure you complete the form accurately and effectively.

Follow the steps to complete the authorization form.

1. Click the ‘Get Form’ button to obtain the form and open it for editing.
2. Begin by filling in your personal information in the designated fields. This includes your name, medical record number, social security number, date of birth, phone number, and address.
3. Next, specify the persons or organizations providing and receiving your medical records. Include their names, addresses, and phone numbers to ensure the information is directed correctly.
4. In the specific description of information section, check the boxes for the types of records you wish to disclose. You can also add additional details in the 'Other' section if necessary.
5. Indicate the purpose of the information disclosure by selecting from the provided options. Ensure to clarify any specific purposes in the 'Other' field if applicable.
6. Review and initial the statements regarding your rights and the revocation of authorization. Ensure that you understand these conditions.
7. Enter the expiration date for this authorization. If you do not specify a date, it will automatically expire six months from the date of signing.
8. Finally, sign and date the form. If applicable, include the printed name of your representative and their relationship to you.
9. Once completed, you can save changes, download, print, or share the form as needed.

Complete your authorization form online to ensure your health information is managed efficiently.