Chcr 004 form 2025

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194 votes

The document is a Patient Authorization form that allows a patient to authorize the disclosure of their Protected Health Information (PHI) from a Centura facility to specified organizations, agencies, or individuals. It includes sections for patient details, purpose of disclosure, types of information to be released, and acknowledges the patient's rights regarding the authorization. The form emphasizes that signing is voluntary and outlines conditions under which the authorization expires.

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Click ‘Get Form’ to open the chcr 004 form in the editor.
Begin by entering the Patient Name, Date of Birth, and Last 4 digits of the Social Security Number in the designated fields.
Fill in the Address, City, State, and Zip Code along with the Telephone Number for accurate identification.
Specify the Centura facility that will release your Protected Health Information by filling in its name and address.
Indicate who will receive this information by completing the Release to section with their details.
Select Treatment Date(s) and specify the Type of Disclosure Authorized & Delivery Instructions based on your needs.
Review and complete any additional sections regarding Pertinent Protected Health Information allowed to be included.
Sign and date the authorization at the bottom of the form, ensuring all information is accurate before submission.

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Versions	Form popularity	Fillable & printable
2012	5 Satisfied (55 Votes)
2012	4 Satisfied (48 Votes)
2011	4.3 Satisfied (194 Votes)

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