Get Hoag Medical Group Authorization For Use Or Disclosure Of Health Information 2020-2025

Filling out the Hoag Medical Group Authorization For Use Or Disclosure Of Health Information form online is a straightforward process. This guide aims to assist you in completing the form efficiently and accurately, ensuring that your health information is disclosed according to your wishes.

Follow the steps to complete your authorization form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the designated fields, including your full name and date of birth. Ensure that the spelling and details are accurate.
3. In the 'Use of disclosure' section, write the name or organization you are authorizing to disclose your health information. Add any relevant attention details and provide the complete address, including city, state, and zip code.
4. Fill in the phone number and fax number for the organization you are authorizing, as this information will facilitate communication regarding your records.
5. Next, indicate that the records are to be released to Hoag Health Information by providing their full address. This section is already pre-filled for convenience.
6. Specify the records to be disclosed by checking the appropriate boxes. These could include labs, history and physical, progress notes, consultation notes, or any other relevant information.
7. If specific dates for the records are needed, indicate those; otherwise, note that if no dates are provided, only records from the last two years will be released.
8. In the section for specially protected information, check any items that apply, such as alcohol/drug treatment information, HIV test results, or mental health treatment information. Be aware that psychotherapy notes require separate authorization.
9. State the purpose for the release of your health information, such as for further medical care or another specified purpose.
10. Sign and date the form in the designated areas. If a legal representative is signing, ensure their relationship to you is noted, and include their printed name.
11. If required, have a witness sign and date the form as well. This step ensures the validity of the authorization.
12. Lastly, once all fields are filled out correctly, review the form for accuracy. You can then save your changes, print, or share the completed form as needed.

Complete your document online today to ensure your health information is shared as required.