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Authorization to Use and Disclose Health Information P A T I E N T Patient Name: Birth Date: Maiden or Previous Name(s): SSN: I authorize: Prior Imaging Facility (name/address of disclosing entity):
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How to fill out maiden or previous names:

01
Start by providing your current legal name as it appears on your official identification documents, such as your passport or driver's license.
02
If you have been previously married and have changed your last name, include your maiden name in the appropriate field. This is important for identity verification purposes and to cross-reference any official documents associated with your previous name.
03
If you have acquired a new last name due to a legal name change, include this information as well.
04
In case you have multiple previous names, use the space provided to list them in chronological order, starting with the earliest name change.
05
Ensure the accuracy and consistency of the information provided, as any discrepancies may lead to complications during official processes or identity verification.
06
Double-check all the entered names before submitting the form to avoid any errors or omissions.

Who needs maiden or previous names:

01
Individuals who have changed their last name due to marriage need to provide their maiden name to establish a connection between their current and previous identities.
02
Divorced individuals who have reverted to their maiden name or changed their last name due to divorce need to provide their previous name as part of the documentation process.
03
In some cases, individuals who have legally changed their name for personal or professional reasons may also need to provide their previous name. This is to ensure consistency and traceability in their official records.
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Maiden or previous names refer to the name a person used before their current legal name, typically a name used before marriage.
Anyone who has legally changed their name, such as through marriage, divorce, or court order, is required to file maiden or previous names.
To fill out maiden or previous names, individuals must provide the name(s) they used before their current legal name.
The purpose of reporting maiden or previous names is to maintain accurate records and ensure proper identification.
The information that must be reported on maiden or previous names includes any names used before the current legal name.
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