Get Avera Health 8691-04 2020

Filling out the Avera Health 8691-04 form online is a straightforward process. This guide will provide you with step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to successfully fill out the Avera Health 8691-04 online.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Begin filling out the patient identification section by entering the patient's full name and date of birth. Make sure the information is accurate to avoid any delays.
3. Provide the patient’s address, including city, state, and zip code, along with the last four digits of their Social Security number and phone number.
4. In the section titled 'Provider', enter the name of the individual or organization that is authorized to release the medical information, followed by their address, city, state, zip, phone, and fax numbers.
5. Under 'Disclose Information to', fill in the name or facility where the information should be sent, along with their address, city, state, zip, phone, and fax numbers.
6. Select the type of medical information to be disclosed by checking the appropriate boxes for standard chart copy, X-ray and imaging reports, entire record, or other specifications.
7. Indicate the dates of service for which the records are being requested by filling in the start and end dates in the provided fields.
8. Choose the preferred method of receiving the records by selecting from options such as paper (pickup or mail), fax, flash drive, CD-ROM, or email, and fill in the email address if applicable.
9. If substance abuse records may be included, check the corresponding box to permit the release of that information.
10. Under 'Purpose of Disclosure', specify the purpose of the request, such as continued healthcare, completion, payment, or other, by checking the appropriate option.
11. Specify an expiration date for the authorization. If left blank, it will be valid for one year.
12. Sign and date the form at the bottom, indicating whether you are the patient or a legal representative. If signed by a legal representative, indicate your relationship to the patient.
13. Lastly, provide a witness signature and date, if required. Once completed, review all the entered information for accuracy.
14. You can now save changes, download, print, or share the form as needed.

Complete your documents online today for a smoother experience.