Get Piedmont Healthcare Authorization For The Use And Disclosure Of Protected Health Information 2021-2025

Completing the Piedmont HealthCare authorization for the use and disclosure of protected health information online is an essential step in managing your health records. This guide provides clear, step-by-step instructions to assist you in accurately filling out the form while ensuring your privacy is maintained.

Follow the steps to complete your authorization form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in your online editor.
2. Begin by entering the patient’s full name in the designated field. Make sure to provide accurate details to avoid any issues with processing your request.
3. Fill in the date of birth to ensure the records are matched correctly with the right individual.
4. Input the complete street address or P.O. Box. This ensures that any records sent can reach you without delays.
5. Provide a contact phone number for both home and work. Having both ensures communication lines remain open.
6. Specify the recipients of the medical records by filling in the name of the person, facility, or physician you need the records sent to (Send Medical Records TO section).
7. In the 'From' section, indicate which doctor or facility the records are to be obtained from.
8. Complete the address fields for both the recipient and the sender, ensuring accuracy for smooth transitions of information.
9. Indicate the date range for which you need the records. This can typically be specified in a From: and To: format.
10. Select the specific types of health information you wish to access by checking the appropriate boxes. Understand what each selection entails to make an informed choice.
11. Review the acknowledgement of understanding regarding the potential risks associated with information disclosure, including re-disclosure to third parties.
12. Sign and date the form at the bottom. If you are acting as a personal representative, please check the appropriate box and include any necessary legal documents.
13. Once all information is thoroughly completed, you may choose to save the changes, download, print, or share the form as necessary.

Take control of your health information today by completing the authorization form online.