Get Authorization For Use And Disclosure Of Health Information. Release Of Information For The Palo Alto Medical Foundation 2020-2025

This guide provides clear, step-by-step instructions to help you successfully complete the Authorization for Use and Disclosure of Health Information form for the Palo Alto Medical Foundation. By following these instructions, you will ensure that your health information is appropriately shared with the intended recipients.

Follow the steps to complete your authorization form effectively.

1. Press the ‘Get Form’ button to access the Authorization for Use and Disclosure of Health Information form. This will open the document in an editor for you to fill out.
2. Begin by entering your full name and date of birth in the designated fields at the top of the form. This identifies you as the patient whose information is being authorized for release.
3. Indicate the specific dates of service for which you are authorizing the release of information. This helps to narrow down the records that will be shared.
4. Provide your phone number for additional contact, should any clarifications be needed.
5. In the section labeled 'I authorize (Name and address),' write the name and address of the organization or individual that holds your health information.
6. In the 'to release to (Name and address of recipient)' section, fill in the information for the person or entity that you wish to receive your health information.
7. Select the items of health information that you are authorizing to be released by checking the corresponding boxes. This can include discharge summaries, progress notes, laboratory tests, and more.
8. If necessary, indicate any restricted access information relating to immunity records, surgery records, or a complete medical record by checking the relevant boxes.
9. Specify the purpose(s) for which the recipient may use your health information in the designated field. Be as clear and specific as possible.
10. Enter the expiration date for the authorization, noting that the form will be valid for one year if no date is provided.
11. Review your rights as outlined in the form. Ensure you understand your ability to refuse to sign, revoke consent, and request copies of the authorization.
12. Sign and date the form where indicated. If someone else is signing on your behalf, provide their name and relationship to you.
13. Finally, check the appropriate box for your medical group and send the completed form to the correct address or fax number provided for your group.

Complete your authorization form online today and ensure your health information is shared securely and efficiently.