Consent to Use and Disclose Protected Health Information form 2025

1. Click ‘Get Form’ to open the Consent to Use and Disclose Protected Health Information form in the editor.
2. Begin by entering the patient's name, home address, and telephone number in the designated fields. Ensure accuracy for effective communication.
3. Fill in the date of birth to confirm the identity of the patient. This is crucial for compliance with health information regulations.
4. Review the list of highly confidential information categories. Check any that apply to authorize their use or disclosure.
5. Specify the purpose for which this information will be used by selecting from options like 'Continuing Medical Care' or 'Personal Use'.
6. Indicate whether you authorize MetroWest Medical Center to release or obtain information by checking the appropriate boxes and providing details about the recipient.
7. Complete any additional sections regarding diagnostic testing, dates of service, and other relevant details as required.
8. Finally, sign and date the form at the bottom. If applicable, have a personal representative sign as well, indicating their authority.

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