Release of Info Authorization (DOH_5032)

Jump to Section: 

Form Details

• Form Properties
  1. Form Title: Release of Info Authorization
  2. Start from an Existing Form – No
  3. Copyrighted Form – No
  4. Billable Progress Note – No
  5. Have multiple versions open at same time – No
  6. Open Blank on new version – No
• Required Fields – Yes
• Lookup Tables – None
• Pre-Fill Logic – Yes
  1. Patient Address will prefill from Patient Details.
• Fill to Logic – None
• Signatures
  1. Patient or Representative signature
     • Manually enter name.
     • Signature required.
  2. Staff Signature
     • Credential required to sign: any sig type.
     • Title will fill title entered in user setup (see eCR University – Users).
     • Signature required.
     • Route To functionality is available.

[Back to Top]

Authorization Tab

1. Patient Address will prefill from Patient Details.
2. Enter the name and address of the provider of entity to release this information.
3. Enter the name and address of person(s) to whom this information will be disclosed.

[Back to Top]

Info Tab

1. Purpose for the release of information – Required field.
2. Date range the information may be disclosed from – Required field.
3. Select the type of information that will be disclosed during the date range.
4. Enter the name of the person signing the form if it is not the patient (if applicable).
5. Enter the authority to sign on the patient’s behalf.

[Back to Top]

Signatures Tab

Signature Credentials

1. Patient or Representative signature
   • Manually enter name.
   • Signature required.
2. Staff Signature
   • Credential required to sign: any sig type.
   • Title will fill title entered in user setup (see eCR University – Users)
   • Signature required.
   • Route To functionality is available.

[Back to Top]