Get Oh Cincinnati Childrens Authorization For Use And/or Disclosure Of Protected Health Information 2021-2025

Filling out the OH Cincinnati Childrens Authorization For Use And/or Disclosure Of Protected Health Information form is essential for allowing Cincinnati Children's Hospital Medical Center to share your protected health information. This guide provides clear instructions on how to complete the form online, ensuring you understand each step.

Follow the steps to effectively complete the authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin filling out the patient information section. You should enter the patient's full name, date of birth, and gender. Ensure accuracy in this section to avoid delays.
3. Provide contact information for the patient or legal guardian completing the form, including name, email address, and physical address.
4. In the 'Release To' section, specify the name and address of the individual or organization to whom the information will be sent.
5. Indicate how the information may be sent. Options include US Mail, MyChart, email, or reviewed in person, ensuring you understand any limitations for specific methods.
6. Select the format in which you would like to receive the copies of your records. Choices include paper, CD, or other specified formats.
7. Specify the purpose for requesting the information by selecting the applicable options such as medical care, legal, personal use, or other reasons.
8. Identify the specific information to be released, including dates of treatment and types of records requested, e.g., medical record abstract, discharge summaries, etc.
9. Review the expiration date for the authorization. It automatically expires one year from the date signed unless a specific expiration date is provided.
10. Submit your signature and date on the document. If you are a guardian or legal representative, ensure that you include your relationship and any required documentation.
11. Once you have completed the form, save your changes and choose an option to download, print, or share the form as needed.

Complete your documents online to ensure proper handling of your healthcare information securely and efficiently.