Get Authorization To Use Or Disclose Or Release - Purdue University - Purdue

This guide provides clear, step-by-step instructions for filling out the Authorization To Use Or Disclose Or Release form from Purdue University. Whether you are a first-time user or have experience with similar forms, this comprehensive guide will assist you in successfully completing the document.

Follow the steps to complete the authorization form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in your personal details in the provided fields. Start with the patient's name, date of birth, and address. Make sure to enter accurate and complete information.
3. In the next section, provide your patient identification number and phone number. This information is important for processing your request.
4. Specify the recipient of the medical records by providing their name and, if available, fax number. Additionally, include their address to ensure that the medical information is sent to the correct location.
5. Describe the specific medical records or health information you wish to be used or released. This should be detailed to avoid ambiguity in your authorization.
6. If you are not the patient, explain the reason for the request in the designated field. This information is important for clarity and records.
7. Review the consent sections regarding the extension of authorization for psychiatric, mental health, and substance use treatment information. Mark the appropriate box for your needs.
8. Acknowledge your understanding of the implications of this authorization by reading the statements provided. This includes understanding re-disclosure risks and the expiration of your authorization.
9. Sign the form, indicating your consent, and specify your relationship to the patient if applicable. If you are a legal representative, print your name as well.
10. Finally, ensure that a witness signs the form if required. Confirm that you have had the opportunity to keep a copy of the completed form.
11. After completing the form, you may save your changes, download it, print a hard copy, or share it as needed.

Complete your authorization form online today to ensure your medical information is handled efficiently and accurately.