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Click ‘Get Form’ to open the dignity health prior authorization form in the editor.
Begin by filling in the patient’s name, date of birth, and any other names used. Ensure that the telephone number and address are accurate for effective communication.
In the 'I AUTHORIZE' section, specify the facility or provider authorized to disclose information. Then, indicate who will receive this information by filling in their details.
Select your preferred method for delivery from the options provided. This includes choices like pick-up at the office or electronic copy via secure email.
If opting for electronic delivery, provide a personal email address and confirm its accuracy with your signature.
Complete any special acknowledgments if applicable, such as mental health records or substance abuse treatment records.
Finally, sign and date the form at the bottom to validate your authorization.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (120 Votes)
2014	4.8 Satisfied (60 Votes)

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