Get Authorization To Disclose Or Request Protected Health Information - Fairfaxcounty

Filling out the Authorization To Disclose Or Request Protected Health Information form is an essential process for allowing the sharing of your protected health information. This guide will provide step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the form and open it in your designated editor.
2. Begin by entering the patient's name in the designated field, ensuring you print the name clearly. Then, provide the patient's date of birth and phone number, using the format mm/dd/yy.
3. Next, fill in the patient's address fully, including street, city, state, and zip code, to ensure clear identification.
4. Identify the service provider by entering the name of the relevant county agency, program, or office, along with its address, to specify where the information will be disclosed.
5. Indicate the name of the person authorized to receive the health information or their designee, along with a supervisor’s name if applicable.
6. Specify the particular type of health information that you authorize to be disclosed. Be as detailed as possible about the information to ensure clarity.
7. Provide the effective dates for the authorization by filling in the start and end dates or specific events triggering the authorization.
8. Determine whether this authorization is for a single-use disclosure or an ongoing disclosure for the specified time period, and check the appropriate box.
9. Explain the purpose of the disclosure clearly, providing enough detail to clarify why this information is being shared.
10. If applicable, review and acknowledge the statement regarding the source records and their protections under federal regulations.
11. Read and understand the conditions of the authorization, including your right to revoke it, the minimum necessary amount of disclosure, and the lack of impact on services.
12. Finally, indicate how and where the authorized information should be sent or communicated, including the address, phone number, or fax number.
13. Sign and date the form, clarifying your relationship to the patient by selecting the appropriate option from the provided choices.
14. After completing all sections, ensure that all information is accurate. You may then save changes, download the document, print a copy, or share it as needed.

Complete your documents online today to ensure your health information is shared securely and efficiently.