Alameda alliance form authorization 2025

1. Click ‘Get Form’ to open the Alameda Alliance for Health Authorization Form in the editor.
2. In Section 1, enter the name of the member or parent/guardian authorizing disclosure. Provide your signature and date, along with your address, city, state, and phone number.
3. Proceed to Section 2 and fill in the name of the Alliance member and their Alliance ID number.
4. In Section 3, review the types of information you are authorizing for disclosure. Ensure you understand that this includes personal health information related to various medical services.
5. For Section 4, appoint your representative by entering their name. Confirm that you authorize them to receive and discuss your personal health information.
6. Finally, in Section 5, have your authorized representative accept their appointment by providing their name, organization (if applicable), signature, date, address, city, state, and phone number.

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