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340 West Lincoln Street, Suite 500 Belleville, IL 62220 618.277.7400 Phone 618.277.7422 Fax Patient Authorization I hereby authorize Lincoln Surgical Associates, Ltd. to release to or obtain from

How to fill out lsa patient authorization form

How to fill out LSA patient authorization form:

1. Obtain the form: Start by locating the LSA patient authorization form. This document may be provided by the healthcare facility or available for download from their website.
2. Read the instructions: Carefully read through the instructions provided on the form. Understand the purpose of the authorization and any specific requirements mentioned.
3. Provide patient information: Fill in the necessary information about the patient for whom the authorization is being granted. This typically includes the patient's full name, date of birth, address, and contact details.
4. Specify the purpose of the authorization: Indicate the specific purpose for which the authorization is being given. This could be for the release of medical records, sharing information with a specific healthcare provider, or any other relevant purpose.
5. Limitations and duration: Specify any limitations or conditions on the authorization, such as a specific time frame during which the authorization is valid. This ensures that the release of information is controlled and in accordance with the patient's wishes.
6. Sign and date: Once all the required information has been provided, sign and date the form. Ensure that the signature is legible and matches the patient's legal signature.

Who needs LSA patient authorization form:

1. Patients: Patients who wish to authorize the release of their medical information to a third party, such as another healthcare provider, insurance company, or legal representative, may need to fill out the LSA patient authorization form.
2. Healthcare providers: Healthcare providers who require the patient's authorization to access their medical records from another facility or to share patient information with other providers may also need the LSA patient authorization form.
3. Legal representatives: In certain cases, legal representatives or guardians may need to complete the LSA patient authorization form on behalf of the patient, especially if the patient is a minor or unable to provide consent themselves.

It is important to note that the specific requirements for the LSA patient authorization form may vary depending on the healthcare facility or jurisdiction. Therefore, it is always advisable to consult the instructions provided with the form or seek assistance from the healthcare facility if any doubts or questions arise during the process.

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