Get Guidelines For Release Of Phi - University Of Pittsburgh

This guide provides detailed instructions for users on how to complete the Guidelines For Release Of Protected Health Information form from the University of Pittsburgh. Follow this comprehensive roadmap to ensure accurate and secure submission of your sensitive information.

Follow the steps to successfully fill out your form online:

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by providing the patient's full name as it appears at the time of treatment. This establishes the identity of the individual whose PHI you are requesting.
3. Enter the patient's identification information, including date of birth, social security number, and medical record number, ensuring accuracy to facilitate proper identification.
4. State the specific purpose for which the PHI will be disclosed, providing clear and concise details.
5. Indicate the unit, department, or School where the encounter occurred, as this is necessary for accurate processing.
6. Fill in the name of the individual or agency to whom the information is to be released.
7. List any relevant dates of treatment to provide context to the request.
8. Specify the exact information to be released, including any sensitive PHI types such as behavioral health, drug and alcohol records, or HIV information.
9. Ensure that the form is signed and dated by the patient or their legal representative, including a description of the authority if a representative is used.
10. Review the revocation statement included in the form to understand how the patient can rescind this authorization at any time.
11. After completing all relevant sections, save your changes, download the form for your records, or print it for physical submission. You may also share it as needed.

Complete your documents online to ensure the best accuracy and compliance.