Get Il Diagnostic Imaging Specialists Of Chicago Authorization For Release Of Confidential Information 2019-2025

Completing the IL Diagnostic Imaging Specialists Of Chicago Authorization For Release Of Confidential Information form is essential for facilitating the release of your confidential medical records. This guide provides clear, step-by-step instructions to assist users in filling out the form accurately and securely online.

Follow the steps to complete the authorization form online.

1. Select the ‘Get Form’ button to access the authorization form and launch it in your online editor.
2. Begin by filling out the patient’s name in the designated space to identify the individual whose information will be released.
3. Enter the date of birth in the appropriate section to verify the patient's identity.
4. Provide the patient's address, ensuring that you include all necessary details for correct identification.
5. Write the last four digits of the social security number in the specified field, which helps further confirm the identity of the patient.
6. Input the daytime phone number to allow for contact regarding any queries or clarifications concerning the authorization.
7. Indicate the name of the party authorized to release the information in the ‘I AUTHORIZE’ section.
8. Specify the facility name where the information will be sent in the ‘TO RELEASE TO’ section.
9. Fill in the recipient's name, address, and phone number so that the information can be accurately directed.
10. Select the specific information to be released by checking the appropriate boxes, providing necessary details about imaging, such as the types and dates of the procedures.
11. Sign and date the form in the provided sections to confirm authorization. If applicable, include the signature of an authorized legal representative.
12. After completing the form, ensure to save your changes, and consider downloading, printing, or sharing the form as needed.

Complete your authorization for release of confidential information online today.