Get Map 751e 2020-2025

The Map 751e form is essential for authorizing the release of medical information pertinent to public health insurance applications. This guide will help you navigate each section of the form, ensuring that you provide the necessary information accurately and efficiently.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, please provide the name and address of the source of medical information, including the ZIP code. This should be clearly printed or typed.
3. Indicate your relationship to the disabled person. This helps clarify the context of the authorization.
4. Next, fill out the section concerning the disabled person. Provide their name and address at the time they had contact with the medical source, including the ZIP code if known.
5. Enter the date of birth of the disabled person. This information is crucial for identification purposes.
6. If known, include the disabled person's identification number which is different from their Social Security number.
7. Provide approximate dates of contact between the disabled person and the source. This can include hospital admissions, treatment dates, and discharges.
8. In the authorization section, confirm that you allow the medical source to disclose information to the Medical Assistance Program regarding all medical records related to the disabled person, including specific details about psychological impairments, daily living capabilities, and work ability.
9. Sign the authorization where indicated. If you are acting on behalf of the disabled person, include your relationship to them.
10. Finally, fill out the date, address, and telephone number of the signer. Ensure all information is accurate and clearly written.
11. Once you have filled out all sections, you can save your changes, download the completed form, print it for records, or share it as needed.

Complete your Map 751e form online today and ensure your medical information is released efficiently.