Get Piedmont Healthcare Authorization For The Use And Disclosure Of Protected Health Information 2013-2025

Completing the Piedmont HealthCare Authorization For The Use And Disclosure Of Protected Health Information online is a straightforward process designed to ensure that your protected health information is shared as you intend. This guide provides clear, step-by-step instructions to assist you in filling out the form accurately and effectively.

Follow the steps to fill out the authorization form online

1. Press the ‘Get Form’ button to access the authorization form and open it in your preferred editor.
2. Begin by entering your full name in the designated field for 'Print Patient Name' at the top of the form.
3. Next, fill in your date of birth in the corresponding section to verify your identity.
4. Input your complete address, including street address or P.O. Box, city, state, and zip code in the fields provided.
5. Provide your home and work phone numbers in the specific fields to ensure communication can be established.
6. In the section labeled 'SEND MEDICAL RECORDS TO,' write the name of the person, physician, or facility that will receive your medical records.
7. Fill in the complete address and phone number & fax number of the recipient to ensure the records are sent accurately.
8. Specify the information that may be used or disclosed by checking the relevant boxes, such as immunization records, office visit notes, or lab reports. Enter any additional information if necessary.
9. Fill in the dates of treatment for which the information applies, ensuring accuracy in the start and end date.
10. Indicate the purpose of the disclosure by selecting from the options provided, such as patient request or transferring physicians, and fill in any other purpose if applicable.
11. Sign and date the authorization form in the designated sections to validate your consent.
12. If you are signing on behalf of the patient, check the legal authority and provide any necessary legal documents.
13. Review all filled sections for completeness and clarity, then save your changes.
14. Finally, download, print, or share the completed authorization form as needed.

Complete your documents online with confidence today.