Get Dignity Health Authorization For Use Or Disclosure Of Protected Health Information 2019

Filling out the Dignity Health Authorization for Use or Disclosure of Protected Health Information online is a crucial step in managing your health records. This guide will walk you through each section of the form to ensure you complete it accurately and efficiently.

Follow the steps to fill out your authorization form online.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. Enter your medical record number and account number in the designated fields at the top of the form.
3. Fill in the patient's name and date of birth. Include any other names used if applicable to ensure proper identification.
4. Provide a telephone number where you can be reached, ensuring clear communication regarding your request.
5. In the 'I AUTHORIZE' section, write the name of the clinic or provider that you are authorizing to disclose the health information.
6. Indicate the individuals or organizations that are authorized to receive the information in the 'TO DISCLOSE TO' section.
7. Provide the complete address of the person or organization receiving your health information.
8. Select the specific types of records you wish to obtain by checking the corresponding boxes. Include any other specific information if needed.
9. Specify the treatment date(s) for which the records are needed. If nothing is specified, records from the last two years will be provided.
10. If you are requesting access to special classes of information, initial next to each applicable item to confirm your request for such information.
11. Select the purpose of the requested use or disclosure from the options provided.
12. Choose the delivery format for the records, providing an email address if you select electronic delivery.
13. Enter the expiration date for the authorization, or let it default to one year from the date of execution.
14. Read and understand your rights as stated. You may refuse to sign the authorization and can revoke it at any time.
15. Sign the form where indicated and provide the date of your signature. If applicable, print the name of a personal representative and their relationship to the patient.
16. Verify your identification initials as required.
17. Review your completed form, then save changes, download, print, or share it as needed.

Complete your Dignity Health form online to manage your health information efficiently.