Get the free OASIS Hospital Authorization for Release of Medical Information
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5-Hole 1/4 1 3/8 c-to-c OASIS Hospital 750 N. 40th Street, Phoenix, AZ 85008 Phone 602-797-7788 Fax: 602-797-7787 Authorization for Release of Medical Information M.R. No. PATIENT S NAME BIRTHDATE
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How to fill out oasis hospital authorization for
How to fill out oasis hospital authorization form:
01
Start by carefully reading the form instructions to ensure you understand the requirements and purpose of the authorization.
02
Fill in your personal information accurately, including your full name, address, contact number, and date of birth.
03
Provide the name and contact information of the patient you are authorizing access to, if different from your own.
04
Indicate the specific purpose of the authorization, such as medical treatment, release of medical records, or communication with healthcare providers.
05
Specify the duration of the authorization, whether it is a one-time authorization or covers a specific period.
06
Sign and date the form, ensuring that your signature matches the name provided.
07
If required, include any additional documentation or attachments mentioned in the instructions.
08
Retain a copy of the completed form for your records.
Who needs oasis hospital authorization for:
01
Patients who want to authorize a specific individual or entity to access their medical records.
02
Individuals acting as legal guardians or representatives of the patient.
03
Family members who may need access to medical information or make decisions on behalf of the patient.
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