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Get Rex Healthcare Authorization For Release Of Information
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How to fill out the Rex Healthcare Authorization for Release of Information online
Completing the Rex Healthcare Authorization for Release of Information form online is a straightforward process that allows you to grant access to your protected health information. This guide will help you navigate each section of the form with ease to ensure all necessary information is accurately provided.
Follow the steps to complete your authorization form
- Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
- Begin by filling out the 'I authorize' section. Here, provide the name of the specific employer or their affiliated workers’ compensation case manager to whom you are granting access.
- Next, fill out the contact information for the employer including their name, address, and phone number to ensure proper identification.
- In the 'protected health information of' section, input your personal details, including your name, address, city, state, zip code, date of birth, social security number, and telephone number to clearly identify yourself.
- Specify the type of injury in the section that asks for treatment/service related to the injury, as well as the date of injury to contextualize the release of your information.
- Under 'check here to select all boxes listed', indicate the specific types of health information you wish to be disclosed by marking the appropriate checkboxes.
- If applicable, provide your initials in the boxes below the 'acknowledge' section to authorize the release of sensitive information concerning mental, drugs & alcohol, HIV/AIDS & other communicable diseases.
- Select the appropriate purpose for the use or disclosure by checking the corresponding box, ensuring it aligns with your needs.
- In the 'expiration' section, you can specify the duration for which this authorization is valid or indicate that it will expire automatically in ninety days if no specific date is provided.
- Finally, ensure you sign the form, along with the date of signature. If an authorized representative is signing, they should provide details about their authority as well.
Complete your documents online to ensure efficient processing.
To request medical records from UNC Rex, you need to complete the Rex Healthcare Authorization for Release of Information form. You can submit this form in person or via mail, depending on your preference. For assistance, reach out to their records department to guide you through the process.
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