Get Authorization For Access, Use And/or Disclosure Of ...

Filling out the authorization for access, use and/or disclosure of protected health information is an essential process for individuals wanting to obtain their medical records. This guide will provide you with clear, step-by-step instructions to ensure the form is completed accurately and efficiently online.

Follow the steps to complete your authorization request.

1. Click the ‘Get Form’ button to acquire the authorization form and open it in an online editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure that the information matches the records held by AdventHealth Redmond.
3. Insert today’s date to indicate when the request is being made.
4. In the section requesting access to your information, indicate your preferred format for receiving the information by circling "Paper," "Electronic," or "Other."
5. Complete the section for disclosing information to another individual or organization, including the name, address, city, state, zip code, phone number, fax number, and email address.
6. Select the reason for your request and provide a specific description of the information you wish to access or have disclosed by checking the appropriate boxes.
7. Review the statements included in the form. Acknowledge your understanding by reading through them carefully, as they detail your rights and the potential for redisclosure of information.
8. Sign and date the form. If applicable, indicate the legal representative's name and attach any necessary documentation.
9. Finalize the process by saving your changes. You can then download a copy of the completed form, print it for your records, or share it as needed.

Complete your authorization form online today to gain access to your health information.