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How to fill out the Henry Ford 26091 online
Filling out the Henry Ford 26091 form online can seem daunting, but with this guide, you will navigate the process with ease. This document is essential for authorizing the access or release of your medical information, allowing you to share your health records with designated parties.
Follow the steps to complete the Henry Ford 26091 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out your personal information in the 'Patient Information' section. Enter your full name, any previous names, current address, city, date of birth, phone number, state, and zip code.
- In the authorization section, state your name to confirm that you authorize the designated parties to access your medical records. Detail what information can be disclosed, primarily focusing on your medical care and specific health conditions if applicable.
- Select the checkboxes for the records you wish to include, such as alcohol and substance use diagnosis and treatment, or psychotherapy notes.
- Identify the recipient of the shared information by providing their name, phone number, address, city, state, and zip code in the 'Release (disclose) Information to' section.
- Next, specify the type of service you are requesting information for, including descriptions and dates of service or other relevant details.
- Clearly indicate whether you would like to obtain a copy, access and inspect your medical record, or consent to verbal communications about your care.
- Complete the expiration date section, ensuring it does not exceed one year from the date of signing the document.
- Sign and date the authorization at the bottom of the form, including your relationship to the patient if you are not the patient themselves.
- Finally, review the completed form for accuracy. You can then save the changes, download, print, or share the form as needed.
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