Get Authorization To Use Or Disclose 06-24-2008 Him.doc - Purdue

Filling out the Authorization To Use Or Disclose form is an important step in managing your healthcare information. This guide provides clear, step-by-step instructions to help you complete the form accurately online.

Follow the steps to complete the authorization form effectively.

1. Click ‘Get Form’ button to access the Authorization To Use Or Disclose form and open it in your preferred document editor.
2. Begin by filling in the patient’s name, date of birth, and address, ensuring all your personal information is accurate.
3. Enter the patient’s identification number and phone number as requested on the form.
4. Identify the recipient of the medical records by writing their name and, if available, the fax number. Include the recipient's complete address.
5. Clearly describe the specific medical records or health information you wish to authorize for release. Be as detailed as possible.
6. If the request is not made by the patient, specify the reason for the request in the designated field.
7. Review the sections about psychiatric, mental health, and substance abuse treatment information. Mark the corresponding 'No' box as necessary.
8. Acknowledge your understanding of the implications of this authorization regarding the re-disclosure of information by the recipient.
9. Sign and date the form, providing your printed name if you are not the patient. If applicable, indicate your relationship to the patient.
10. If required, have a witness sign the document, and ensure they write the date of signature. Confirm whether the patient wishes to receive a copy of this form.
11. Once completed, save your changes, and you can choose to download, print, or share the form as needed.

Complete your documents online efficiently and ensure your healthcare information is managed correctly.