Get Ct F4918eng 2019-2025

Filling out the CT Yale New Haven Health F4918Eng form is an important step in authorizing the release or acquisition of medical information. This guide provides clear, step-by-step instructions to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the CT Yale New Haven Health F4918Eng form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter your legal name in the designated fields. Provide your last name, first name, middle initial, and preferred name if applicable.
3. Fill in your date of birth to ensure accurate identification.
4. Provide your contact details, including phone number and email address, to facilitate communication.
5. Complete your address, including street or box number, city, state, and zip code.
6. Select the purpose for which the information will be used by checking the appropriate box. Options may include personal use, insurance eligibility/benefits, or others.
7. Indicate any other names you might have used by filling in the maiden or other name section.
8. Specify who the information should be released to or obtained from by providing their name, contact details, and address.
9. For medical records from external providers, specify the Yale New Haven Health Services location for sending the medical information.
10. Choose a preferred method of disclosure by selecting from the options available, such as MyChart, mail, fax, secure email, or pick-up.
11. Indicate your preferred contact method for pick-up if applicable.
12. Select the visit type by checking the corresponding box for admission, outpatient surgery, emergency department visit, or others.
13. Specify the location of service by checking the applicable Yale New Haven Health facility.
14. List the dates of service relevant to the request.
15. Select the specific medical information you are requesting from the list provided.
16. If applicable, indicate any information you do not want released by initialing the appropriate boxes.
17. Read and acknowledge the terms outlined regarding the authorization, then sign and date the form.
18. Return the completed authorization by mail, fax, or email as specified.

Complete your CT Yale New Haven Health F4918Eng form online today.