Get Hi Dhs 1124 2005-2025

The HI DHS 1124 form is essential for authorizing the disclosure of confidential information to the Med-QUEST Division. This guide will support you step-by-step in completing the form accurately and effectively.

Follow the steps to successfully fill out the HI DHS 1124 online.

1. Click ‘Get Form’ button to retrieve the form and access it for completion.
2. In Section (1), print your name in the format of Last, First, Middle Initial.
3. In Section (2), provide your legal representative's description of authority if applicable.
4. In Section (3), print the name of the person or agency you authorize to disclose information.
5. Check the boxes for the types of information you are authorizing to be disclosed, such as Medical Records or Enrollment.
6. If required, specify any other information in the space provided. Indicate service dates in the designated fields.
7. In Section (4), provide the name of the individual whose information is being shared. Also, complete Section (5) with their Social Security Number.
8. Fill in your mailing address and contact information in Sections (6) and (7). This includes your city, state, zip code, and telephone number.
9. In Section (8), describe the purpose for which the information will be used.
10. Indicate in Section (9) any specific date or event that limits the duration of the authorization, if applicable.
11. Review the understanding points outlined in the authorization section to ensure you grasp all implications.
12. Sign and date the form in Section (10) to finalize your authorization.
13. Once completed, you can save your changes, download, print, or share the form as needed.

Complete your documents online and ensure your requests are effectively processed.