Omh 11c 2025

1. Click ‘Get Form’ to open the OMH 11c in the editor.
2. Begin by entering the Patient’s Name (Last, First, M.I.) and 'C' No. in the designated fields at the top of the form.
3. Fill in the patient's Date of Birth and Sex to ensure accurate identification.
4. In Part 1, specify the Description of Information to be Used/Disclosed and provide a clear Purpose or Need for Information by selecting appropriate options.
5. Complete the sections for both 'From' and 'To', detailing names, addresses, and titles of individuals or organizations involved in the disclosure.
6. Sign and date where indicated to authorize the release of information. If applicable, include details about your authority if signing as a personal representative.
7. If revocation is needed later, navigate to Part 2 and fill out accordingly to revoke any previous authorizations.

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