Follow the steps to complete the Sentara HIMROI001 form online.

1. Press the ‘Get Form’ button to access the Sentara HIMROI001 form and open it for editing.
2. Begin by filling in the patient label section. Enter the patient's name, Social Security Number or Medical Record Number, date of birth, daytime phone number, and address.
3. Indicate your preferred method of receiving the information by selecting either 'Mail' or 'Pick Up' and provide the necessary details.
4. In Part 1, check all applicable types of records that you wish to be released, and specify the relevant dates of service for each type.
5. In Part 2, select the specific information that will be included with your electronic visit summary, such as allergies, consultation reports, and discharge instructions.
6. In Part 3, acknowledge any sensitive information by indicating if you do not wish to release information related to sexually transmitted diseases, mental health services, or substance abuse. Initial next to your choice.
7. In Part 4, specify the entities to whom the information will be disclosed and the purpose for the disclosure.
8. Read and understand your rights regarding revocation of this authorization as described in the form. Specify an expiration date or condition for the authorization if desired.
9. Indicate whether Sentara will or will not be remunerated for this disclosure and ensure you have understood the implications of the authorization.
10. Finally, provide the signature of the patient or legal representative, then enter the date of signing. Ensure all information is accurate before proceeding.
11. Once you have completed all sections of the form, remember to save your changes, download a copy, print it, or share it as needed.

Complete your document online to manage your health records more effectively.