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Click ‘Get Form’ to open it in the editor.
Begin by entering the patient's name, Social Security Number (SSN) or Medical Record Number, and Date of Birth in the designated fields.
Provide a daytime phone number for contact purposes.
In section 1, authorize the use or disclosure of health information by clearly stating your consent.
Identify the individual or organization authorized to make the disclosure in section 2, including their address.
Specify the type and amount of information to be disclosed in section 3. Check all applicable boxes and include relevant dates where necessary.
In section 5, indicate who will receive this information and for what purpose.
Review section 6 regarding your right to revoke this authorization and specify an expiration date if desired.
Sign and date the form at the bottom. If signed by a legal representative, include their relationship to the patient.

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What is disclosure authorization?

This is a form used in the nonstandard auto market, for people who do not qualify for automobile insurance from the usual sources because of their bad driving record. Such drivers are required to sign a disclosure authorization form before coverage can be put in force.

What is an authorization to disclose?

A covered entity may disclose PHI without the individuals permission for treatment, payment, and health care operations purposes. For other uses and disclosures, the Privacy Rule generally requires the individuals written permission, which is an authorization that must meet specific content requirements.

What does authorization to disclose mean?

The authorization provided by use of the form means that the organization, entity or person authorized can disclose, commu- nicate, or send the named individuals protected health information to the organization, entity or person identified on the form, including through the use of any electronic means.

What is a VA Form 21 4142 authorization to disclose information?

Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.

What is an authorized disclosure?

Disclosure is authorized if the respondent consented to making confidential information known to a third party. An example of authorized disclosure is providing record-level information to a Designated Agent for statistical purposes.

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