Get Lawrence General Hospital Authorization To Use Or Disclose Protected Health Information 2013-2025

Completing the Lawrence General Hospital Authorization to Use or Disclose Protected Health Information form is essential for allowing designated individuals or organizations to access your medical records. This guide offers a clear, step-by-step approach to ensure you fill out the form accurately and efficiently online.

Follow the steps to complete the authorization form online.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. In the 'Patient Name' field, please clearly print your full name as it appears on your medical records.
3. Enter your 'Date of Birth' in the specified field in the format of MM/DD/YYYY.
4. Fill in your 'Address,' ensuring to include street, city, state, and zip code for accurate identification.
5. Provide your 'Social Security Number' and 'Contact Telephone Number' in the respective fields.
6. In the 'Recipient' section, print the full name of the individual or facility that will receive your information.
7. Include the recipient's 'Fax Number' and 'Address' to ensure proper delivery.
8. Specify the 'Treatment Dates' by indicating the range of dates during which treatment occurred.
9. Select the type of information you would like to be disclosed by checking the appropriate boxes for medical documents.
10. If any highly confidential information is to be shared, please check those specific categories and provide your authorization by signing next to each relevant box.
11. Choose the 'Purpose of the Disclosure' by checking the appropriate box.
12. It is imperative to sign the form on page 2 for the authorization to be valid.
13. Indicate the term for which this authorization will remain in effect.
14. Review all entries for accuracy before submitting the form online.
15. Once completed, save your changes, and proceed to download, print, or share the completed authorization form as needed.

Complete your authorization form online today for a smooth and efficient process.