Get Ah-216a Dt-9113 2004-2025

The AH-216A DT-9113 form is crucial for authorizing the release of medical information. This guide provides clear, step-by-step instructions to help you complete this form online with ease.

Follow the steps to fill out the AH-216A DT-9113 form accurately.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your surname and given name(s) as they were at birth in the designated fields.
3. Next, fill in your current name as it is used now.
4. Provide your present address in the relevant space on the form.
5. Enter your file number and RAMQ number if applicable.
6. Complete your birth date by entering the year, month, and day in their respective fields.
7. Provide the surname and given name(s) of your father in the following section.
8. Add the name(s) of your mother in the specified area.
9. List any other names you have used previously, if applicable.
10. In the next section, identify yourself by entering your name and address.
11. Indicate your capacity: whether you are the user or an authorized person.
12. Authorize the establishment to send the specified information to the designated recipient.
13. Clarify the details concerning the care or services received during the relevant time period.
14. Specify that the consent is valid for a period of days following the date of signing.
15. Sign the form in the designated area, indicating whether you are the user or an authorized person.
16. Enter the date of signing, including the year, month, and day.
17. Lastly, have a witness sign in the designated location to validate the form.
18. Once completed, save your changes, download, print, or share the form as needed.

Complete your AH-216A DT-9113 form online today to ensure timely processing.