Dignityhealth contentdamAUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Medical Record and Account numbers at the top of the form. This information is crucial for identifying your records.
3. Fill in your personal details, including your Name, Date of Birth, Other Names Used, and Telephone Number. Ensure accuracy to avoid any delays.
4. In the 'I AUTHORIZE' section, specify the Clinic or Provider you are authorizing to disclose your health information.
5. Next, indicate who will receive this information by filling in their name and address in the 'TO DISCLOSE TO' section.
6. Select the types of records you wish to request by checking the applicable boxes. You can choose multiple options based on your needs.
7. If applicable, initial next to any special classes of information that require additional authorization.
8. State the purpose for which you are requesting this information and select your preferred delivery format from the options provided.
9. Finally, sign and date the form at the bottom. Make sure to print your name if you are a personal representative.

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