Get Nv Renown Health Form 100‐014 2019-2025

This guide provides a clear and supportive walkthrough for users looking to complete the NV Renown Health Form 100‐014 online. Whether you are releasing your health information for personal or legal reasons, this guide will help you navigate each section of the form with confidence.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the NV Renown Health Form 100‐014 and open it in your preferred online editor.
2. Begin by filling in the patient’s name, including the first name, middle initial, and last name. Provide the date of birth for accurate identification.
3. Next, enter the patient's address, ensuring to include the street address, city, state, and zip code. Additionally, provide a contact telephone number.
4. Indicate whether you authorize Renown Health to send or receive information by circling the appropriate option.
5. In the section for entity details, specify the name of the individual or organization that will be involved, along with their contact telephone and fax numbers.
6. Clearly state the purpose of the request by checking the applicable boxes, such as treatment, personal request, or legal purposes. You may also provide additional information if needed.
7. Input the specific dates of service for which information is being requested; ensure both start and end dates are included.
8. Choose the types of information that you wish to disclose by checking the appropriate boxes for each category.
9. If there are any additional records you wish to disclose, such as billing records or radiology films, check the respective boxes.
10. If applicable, initial next to the specific authorizations for the release of sensitive records, such as drug and alcohol records or mental health records.
11. Review the understanding statement carefully regarding the expiration of the authorization and the voluntary nature of signing.
12. Finally, complete the signature section. If you are not the patient, ensure to provide your printed name, authority to sign, and attach proof of authority if necessary.
13. Once all sections are filled, review the form for accuracy, and proceed to save any changes, download, print, or share the completed form as required.

Complete the NV Renown Health Form 100‐014 online today to efficiently manage your health information.