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OB-GYN Health Center of Volusia, LLCPATIENT FORMS

OB-GYN Health Center of Volusia, LLCPATIENT FORMS 2025

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The document is an authorization form for the release of protected health information from Dedicated to Women OB-GYN, P.A. It includes sections for personal details of the individual whose records are being disclosed, the entity holding the records, the purpose of the release, and information regarding fees and processing time. The form also outlines the rights of the individual to revoke authorization and provides a certification section for signature.

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1 by entering your name, birth date, address, phone number, and social security number. Ensure all information is accurate for proper identification.
In Section 2, specify the person or entity that has your protected health information. You can select 'Dedicated to Women OB-GYN' or provide another facility's name and contact details.
For Section 3, indicate the description of the health information to be released. Choose between 'All' or 'Specific Dates of Service', and check any sensitive diagnosis boxes if applicable.
Section 4 requires you to identify who will receive your health information. Again, you can choose 'Dedicated to Women OB-GYN' or provide another recipient's details.
In Section 5, describe the purpose for releasing your health information by selecting from options like 'Transfer of Care' or 'Legal'.
Complete Section 6 by specifying the duration of authorization. If no date is provided, it will expire one year after submission.
Review Section 7 regarding fees for copying medical records and processing time frame; ensure you understand potential costs involved.
Finally, sign and date in Section 8. If signing on behalf of someone else, include your authority and attach necessary documentation.

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