Get Ma Fenway Health Authorization For Disclosure Of Protected Health Information 2021-2025

Filling out the MA Fenway Health Authorization For Disclosure Of Protected Health Information is an important step for users seeking to share their protected health information. This guide will walk you through each section of the form to ensure a smooth and efficient completion process.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill out the patient information section. Provide your full name, any alternate name, date of birth, address, phone number, email address, and indicate your preferred method of contact for medical records.
3. In the ‘FROM’ section, provide the sender or facility’s name, phone number, address, and fax number for where your health information will be released from.
4. In the ‘TO’ section, fill in the recipient or facility’s name, phone number, address, and fax number for the location where you want your health information sent.
5. Select the reason for release from the options provided. You can choose multiple reasons, including legal, insurance, or others and specify if necessary.
6. Indicate which information is to be disclosed by selecting the appropriate options from the list available. You may choose all records, abstracts, and specific types of records such as optometry or dental records.
7. Address the sensitive information section. Initial next to each type of sensitive record you want to be released, ensuring you complete this section to avoid delays.
8. Sign the authorization statement, confirming you understand the terms. Include your signature or that of an authorized agent along with their relationship to you.
9. Finally, save your changes. You may download the form, print it, or share it as necessary.

Complete your forms online today to manage your health information effectively.