93 DBHDS AUTHORIZATION FOR USE/DISCLOSURE OF ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and social security number in the designated fields. Ensure accuracy as this information is crucial for identification.
3. In the section labeled 'Extent or nature of disclosure', check all applicable boxes that indicate what information you wish to disclose, such as discharge summaries or treatment plans.
4. Specify the purpose for the disclosure in the provided field. This helps clarify why the information is being shared.
5. Fill in the names of individuals or entities with whom you are authorizing information exchange. Be precise to avoid any confusion.
6. Review the authorization statement carefully. Once satisfied, sign and date at the bottom of the form to validate your consent.
7. If you need to cancel permission later, complete the cancellation section at the end of the document and sign again.

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