Get Ma Fenway Health Authorization For Disclosure Of Protected Health Information 2010-2025

Filling out the MA Fenway Health Authorization For Disclosure Of Protected Health Information online allows you to authorize the release of your protected health information. This guide will walk you through each step of the process, ensuring that you complete the form accurately and efficiently.

Follow the steps to fill out the authorization form online:

1. Press the ‘Get Form’ button to access the authorization form and open it in your preferred online document editor.
2. Begin by entering your personal information in the designated fields. This includes your name, address, phone number, social security number, date of birth, and maiden name if applicable.
3. In the next section, specify the name and title of the individual or organization you are authorizing to release your health information, along with their address and phone number.
4. Indicate to whom your health information will be disclosed by filling out the name and title, as well as the organization or department’s address and phone number.
5. Select the specific records you wish to authorize for disclosure by checking the appropriate box: either 'All records', records for a specific diagnosis, or records from a particular time period.
6. Choose the reason for the disclosure by checking the relevant box. This may include reasons such as transfer of care or another specified reason.
7. If applicable, indicate the sensitive information categories you authorize to be released by signing next to each category that applies to you, along with the date of treatment.
8. Review the validity period of your authorization, which is valid for the request only and expires after ninety days unless revoked.
9. Sign the form at the bottom, either as the patient or an authorized agent. Clearly specify your relationship to the patient if signed by an agent.
10. In the witness signature area, a witness should sign and date the form to complete the process.
11. Finally, once all information is accurately filled out, you can save changes, download, print, or share the completed form as needed.

Complete your authorization request online today!