Get Hca 12515061.1 2007-2025

Filling out the HCA 12515061.1 form is an essential step in authorizing the use and disclosure of your image, voice, and written testimonials. This guide helps you navigate the online process clearly and effectively, ensuring that you complete every section accurately.

Follow the steps to fill out the HCA 12515061.1 form online.

1. Use the 'Get Form' button to access the HCA 12515061.1 form and open it in the online editor.
2. Begin with the 'Consent for Use and Disclosure of Image, Voice and/or Written Testimonials' section. Carefully read the consent terms ensuring you understand the scope of the authorization being granted.
3. In the signature field, provide your signature or that of your legal representative, confirming your voluntary agreement to the terms outlined in the consent.
4. Next, you will need to print your name, the date, and, if applicable, the relationship of the legal representative to the patient. Make sure this information is correct and corresponds with the correct parties.
5. Proceed to fill out the 'Authorization for Use and Disclosure of Protected Health Information for Marketing and/or Promotional Purposes' section. Include the facility name, your printed name, date of birth, address, and phone number as indicated.
6. Specify the information to be released, covering the required periods of healthcare, and indicate the type of information (e.g., video images, testimonials).
7. Address the purpose of the request, highlighting that it is for marketing purposes and review the compensation aspect by selecting 'Yes' or 'No' for payment to the facility.
8. If applicable, respond to questions regarding the release of any sensitive information, signing appropriately.
9. Fill out the expiration and right to revoke authorization details, specifying how long the authorization remains valid.
10. Finally, check the form thoroughly for any errors or omissions, then save changes, download, print, or share the completed form as needed.

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