Get the free Thurston medical clinic authorization to use/disclose health information

THURSTON MEDICAL CLINIC AUTHORIZATION TO USE/DISCLOSE HEALTH INFORMATION 147 S 52nd Pl, Springfield, OR 97478 Phone (541) 746-1166 FAX (541) 746-6736 Circle one Release PHI to Obtain from Name & Address

How to fill out thurston medical clinic authorization

Who needs thurston medical clinic authorization?

1. Patients who wish to authorize the thurston medical clinic to access their medical records or share their medical information with other healthcare providers or third parties may need to fill out the authorization form.
2. Patients who want a family member, such as a spouse or parent, to have access to their medical information or make medical decisions on their behalf may also require thurston medical clinic authorization.
3. Patients who are participating in medical research studies or clinical trials may need to provide authorization for their medical information to be shared with the research team.

How to fill out thurston medical clinic authorization:

1. Begin by obtaining the thurston medical clinic authorization form. This form is usually available at the clinic's reception desk or can be downloaded from their website.
2. Fill in the patient's personal information accurately, including their full name, date of birth, address, and contact information.
3. Specify the purpose of the authorization by selecting the appropriate checkboxes. For example, if you want the clinic to share your medical records with another healthcare provider, check the corresponding box.
4. If you want to grant access to a specific individual, such as a family member or designated representative, provide their full name and contact information in the designated fields.
5. Determine the scope of the authorization by indicating the specific medical information or records you are authorizing the clinic to disclose or access. This can include medical history, lab results, treatment plans, or any other relevant information.
6. Read and understand the authorization's duration and expiration dates. Many authorizations have an expiration date, and some may allow you to specify the duration of the authorization.
7. Review the authorization form thoroughly to ensure all information provided is accurate and complete. Make any necessary corrections or additions.
8. Sign and date the authorization form in the designated spaces. If necessary, have any required witnesses or notaries sign the form as well.
9. Make a copy of the completed authorization form for your records before submitting it to the thurston medical clinic. It's always a good idea to keep a copy for future reference.
10. Once completed, submit the authorization form to the appropriate department at the thurston medical clinic, such as the medical records department or the front desk.

Remember, it's important to consult with the thurston medical clinic or any legal professionals if you have any questions or concerns about filling out the authorization form.

For pdfFiller’s FAQs

What is thurston medical clinic authorization?

Thurston medical clinic authorization is a form that allows the clinic to obtain patient medical records and information for treatment purposes.

Who is required to file thurston medical clinic authorization?

Patients or their legal guardians are required to file Thurston medical clinic authorization.

How to fill out thurston medical clinic authorization?

Thurston medical clinic authorization can be filled out by providing personal information, medical history, and signing the form.

What is the purpose of thurston medical clinic authorization?

The purpose of Thurston medical clinic authorization is to allow the clinic to access and use the patient's medical information for treatment.

What information must be reported on thurston medical clinic authorization?

Thurston medical clinic authorization must include the patient's name, date of birth, medical history, and treatment preferences.

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