PROOF - Dignity Health - dignityhealth 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated field. Ensure accuracy as this is crucial for identification.
3. Fill in the date of birth and any other names used by the patient. This information helps in verifying the patient's identity.
4. Provide a telephone number and medical record or account number if applicable. This assists in tracking and managing records efficiently.
5. In the authorization section, specify who is authorized to receive the information by filling out their details, including address.
6. Select the types of health information you wish to disclose by checking the appropriate boxes. Initial next to each selected item for confirmation.
7. Indicate the purpose of disclosure by selecting from provided options or specifying another reason.
8. Complete the expiration date section, noting that it will automatically expire one year from signing unless specified otherwise.
9. Sign and date at the bottom of the form, ensuring all fields are completed before submission.

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