Get Nv Summerlin Hospital 79277406 2020-2025

Filling out the NV Summerlin Hospital 79277406 form for authorization to use and disclose protected health information (PHI) is an important process that requires attention to detail. This guide provides a clear and user-friendly breakdown of each section, ensuring that you understand how to complete the form accurately and efficiently.

Follow the steps to successfully complete the form online.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Initial the first box if you are requesting records from Summerlin Hospital, including any request to disclose records to another healthcare provider for continued patient care.
3. Initial the second box if you are requesting to have records sent from another facility to Summerlin Hospital.
4. Initial the third box if you are requesting to view original medical records at Summerlin Hospital, noting that this will be done under supervision.
5. Provide the patient's name at the time of treatment, date of birth, and Social Security number.
6. Fill in the home and work telephone numbers, along with the street address of the patient or the address to which records are to be mailed.
7. Indicate the person(s)/organization authorized to receive the records by checking the appropriate box. If Summerlin Hospital is sending records to another provider, include their name, address, phone number, and fax number.
8. Specify the purpose of the disclosure, choosing from options such as continued patient care, personal use, or attorney.
9. Describe the specific records to be copied or sent, providing accurate treatment dates and checking the appropriate types of documentation requested.
10. Initial next to any highly confidential information that you are authorizing for disclosure. Failing to initial these items may delay processing.
11. List an expiration date or event for this authorization. This cannot exceed one year from the date of the request.
12. Sign and date the authorization to validate it. Unsigned forms will not be honored.
13. If applicable, indicate the reason if the patient is unable to sign, and have the legal representative print and sign their name, date the form, and indicate their relationship to the patient.
14. Select whether the PHI is to be mailed, picked up from Summerlin Hospital, or faxed.

Complete your documents online today to ensure a smooth processing experience.