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                Get Hi Dhs 1123 2006-2025
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How to fill out the HI DHS 1123 online
The HI DHS 1123 form is essential for authorizing the disclosure of confidential information by the Med-QUEST Division. This guide aims to provide a clear and supportive approach to filling out the form online, ensuring users understand each step thoroughly.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
 - Fill in your name in the format: Last, First, Middle Initial. This should be the applicant, recipient, or legal representative.
 - Indicate your legal representative's authority if applicable by printing it clearly below your name.
 - Identify the specific information you authorize the MQD to provide by checking the appropriate boxes for eligibility, enrollment, and any other relevant details.
 - If applicable, provide service dates for the information you wish to disclose, using the format: Month/Day/Year.
 - Initial in the spaces provided to authorize disclosures of specially protected health information, like HIV/AIDS, mental health, or substance abuse treatment.
 - Print the name of the person or agency you are authorizing to receive the information along with their birth date.
 - Complete the address details of the authorized person or agency, including the city, state, and zip code.
 - Fill in your telephone number for contact purposes.
 - Clearly state the purpose for which the information will be used.
 - Indicate the duration for which this authorization is valid by filling in the date or event information.
 - Sign and date the form in the designated area, ensuring to include your mailing address.
 - Review all information provided for accuracy before saving changes, downloading, printing, or sharing the completed form.
 
Ensure your eligibility or authorized disclosures are handled efficiently by completing the HI DHS 1123 online today.
Filling out an authorization for the release of health information involves using the HI DHS 1123 form. Begin by entering the patient's basic information and specifying which records can be released. Make sure to detail the recipient's information and check the appropriate boxes to clarify the purpose of the authorization, ensuring a clear understanding of the request.
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