Get Purdue University Authorization For Use, Disclosure ... - Purdue

Filling out the Purdue University authorization for use, disclosure, or release of protected health information and medical records form is essential for ensuring that your medical information is shared correctly and securely. This guide will provide you with clear, step-by-step instructions to navigate the form efficiently.

Follow the steps to complete your authorization form

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing platform.
2. Enter the patient's name in the designated field at the top of the form. Ensure that the name matches the official identification documents.
3. Fill in the patient's date of birth. This information is crucial for accurately identifying the medical records.
4. Provide the patient's complete address, ensuring all details such as street, city, state, and zip code are correctly filled out.
5. Record the patient's identification number in the appropriate section. This is often assigned by Purdue University.
6. Input the patient's phone number where they can be reached for any clarifications or follow-up.
7. Specify the person or entity who will receive the medical records. This should include detailing the supervisor and department involved.
8. Clearly describe what medical records or other health information you are requesting to be used or released. In this case, include immunization records as specified.
9. If the request is not made by the patient, explain the reason for the request in the designated area, focusing on the necessity for billing purposes.
10. Review the terms and conditions regarding the release of information and your rights concerning the authorization, ensuring you understand the implications of disclosing this information.
11. Sign the authorization form, providing your name and relationship to the patient if you are not the patient themselves. Include the date of the signature.
12. If applicable, a witness should sign and date the form in the provided section.
13. Finally, ensure you save changes, download a copy for your records, print the document, or share it as necessary.

Complete your authorization forms online today to ensure your medical information is released securely and efficiently.