Holy spirit hospital patient information 2025

1. Click ‘Get Form’ to open the holy spirit hospital patient information document in the editor.
2. Begin by entering the patient's name in the designated fields. Ensure that you print clearly for accurate processing.
3. Fill in the patient's street address, city, state, and zip code. Double-check for any typos to avoid delays.
4. Input the patient's date of birth and social security number. This information is crucial for identification purposes.
5. Specify the name and address of the person or agency receiving the medical records. Include their phone and fax numbers if applicable.
6. State the purpose for requesting this information in the provided space, ensuring it aligns with your needs.
7. Indicate the treatment dates relevant to this request by filling in both start and end dates.
8. Select which medical records you wish to receive by checking the appropriate boxes. Be mindful of sensitive information categories.
9. Sign and date the form as either the patient or a personal representative, including your relationship to the patient.
10. Finally, ensure all sections are completed before submitting. Remember that this authorization will expire within one year unless specified otherwise.

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