Get Dignity Health Authorization For Use Or Disclosure Of Protected Health Information 2004

Completing the Dignity Health Authorization For Use Or Disclosure Of Protected Health Information form is essential for authorizing the release of your health information. This guide will provide you with straightforward instructions to fill out the form effectively online.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the authorization form and open it in the designated editor.
2. Fill in the name of the patient and their date of birth in the specified fields. Include any other names used and the telephone number for better identification.
3. Enter the medical record or account number, which is for hospital use only. This information helps to streamline the processing of the request.
4. In the authorization section, specify the facility or provider, which is St. Mary Medical Center, and clearly enter the name of the persons or organizations authorized to receive the health information.
5. Provide the complete address of the designated recipients, including street, city, state, and zip code. This ensures that the health information is directed to the correct location.
6. Indicate the types of health information you are authorizing for disclosure by checking the appropriate boxes. Initial next to the selected information for confirmation.
7. If applicable, mark the specific records or types of health information you want to include in the release. You can choose from various options such as billing records, emergency room documents, and laboratory tests.
8. State the purpose of the requested disclosure. You may choose 'At the request of the patient or personal representative' or specify another reason.
9. Set the expiration date for the authorization. This will default to one year from the date of execution unless you specify a different date.
10. Review and acknowledge your rights regarding the authorization, including the right to refuse to sign and revocation processes. Ensure all necessary signatures are provided.
11. Complete the identification verification section if a personal representative is signing the form. This includes initials and department information.
12. Once all fields are complete, you can save your changes, download a copy for your records, print the form, or share it as needed.

Complete your Dignity Health Authorization for Use or Disclosure of Protected Health Information online today.