1050 Linden Avenue - dignityhealth-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in any other names used by the patient and their telephone number. This helps maintain comprehensive records.
4. Provide the medical record or account number if applicable, which is for hospital use only.
5. In the 'I AUTHORIZE' section, specify the facility or provider authorized to disclose information. Here, you will enter 'St. Mary Medical Center'.
6. Indicate who will receive the disclosed information by filling in their name and address accurately.
7. Select the types of health information to be disclosed by checking the appropriate boxes and initialing next to them.
8. Complete the purpose of disclosure and expiration date sections as required.
9. Finally, sign and date at the bottom of the form, ensuring that all provided information is correct before submission.

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