Get Upmc Hamot Ham-0048 2012-2025

The UPMC Hamot HAM-0048 form is essential for authorizing the disclosure of health information. This guide provides step-by-step instructions to help you efficiently complete the form online.

Follow the steps to fill out the UPMC Hamot HAM-0048 form.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. In Section A, enter the full patient name in the designated field. Select one of the three authorization options that best fit your situation, including your date of birth.
3. If you selected Choice 2 in Section A, complete Section B. Indicate how you would like to receive your records; options include receiving them by mail, having someone else pick them up, or making an appointment to review them at the Medical Records Office.
4. Complete Section C by providing the name and address of the person or entity that will receive the information, along with their telephone number, purpose for disclosure, and a detailed description of the specific information requested.
5. If applicable, initial to authorize the disclosure of mental health records, drug and/or alcohol treatment information, or HIV status in the appropriate boxes.
6. Sign and date the Authorization at the designated places. Ensure to include the time and a daytime telephone number.
7. If the form is signed by a legal representative, complete the section outlining the authority under which they are acting, including necessary documentation if required.
8. For disclosures involving mental health or drug/alcohol treatment information, complete Section D.
9. After you have filled out all sections, review the form for completeness and accuracy. Save your changes, download, print, or share the completed form as needed.

Complete your UPMC Hamot HAM-0048 form online today for quick and efficient processing.