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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the Patient’s Name, Date of Birth, and Medical Record # in Section 1. Ensure that you verify your identity using one of the provided options.
- Fill in the Patient’s Address, including City, State, and Zip Code. Optionally, provide the last four digits of the SSN and Phone #.
- If applicable, indicate if the patient is an employee by checking the corresponding box.
- In Section 2, enter the Name of Representative and their Relationship to Patient. Provide their Address and Phone Number as well.
- Complete Section 3 by specifying where to send the PHI. Include any necessary details about the facility or person receiving this information.
- In Section 4, authorize the release of PHI by signing at Box 25 and dating it appropriately.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2015 | 4.8 Satisfied (164 Votes) |
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