Sentara authorization to disclose form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, Social Security Number (SSN), and date of birth in the designated fields. This information is crucial for identifying the individual whose health information is being disclosed.
3. Provide a daytime phone number for contact purposes. This ensures that any follow-up questions can be addressed promptly.
4. In section 1, authorize the use or disclosure of health information by clearly stating who is authorized to make this disclosure. Fill in their name and address in the provided fields.
5. Specify the type and amount of information to be disclosed in section 3. Check all applicable boxes and include relevant dates where necessary.
6. Complete section 5 by indicating who will receive this information and for what purpose. Ensure that all details are accurate to avoid any issues.
7. Review section 6 regarding your rights concerning revocation of this authorization. Make sure you understand your rights before signing.
8. Finally, sign and date the form at the bottom, ensuring that if signed by a legal representative, their relationship to the patient is also noted.

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