AHP Injury Information Form 2025

1. Click ‘Get Form’ to open the AHP Injury Information Form in the editor.
2. Begin by entering your personal details in the 'Patient Details' section. Include your full name, date of birth, address, plan ID number, social security number, email, and telephone number.
3. If the patient is under 18 years old, provide the guardian or legal representative's information. Fill in their name, address, telephone number, and email.
4. In the 'Release of PHI' section, specify who is authorized to disclose your protected health information. Clearly indicate the names or classes of persons allowed to receive this information.
5. Answer questions regarding mental health information and substance abuse disclosures by selecting 'Y' for yes or 'N' for no as required.
6. Complete the 'Person/Organization to Release Information' section with The Kempton Group Administrators’ contact details.
7. Indicate any expiration date for this authorization if desired; otherwise, it will remain valid for 12 months.
8. Finally, sign and date the form. If applicable, have a guardian complete their details if you are under 18 years of age.

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