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855 668 0697-2026
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- Click ‘Get Form’ to open the Authorization for Release of Protected Health Information (PHI) in the editor.
- Begin with Section A. Fill in your Patient Name, Birth Date, and the Last Four Digits of your SSN if desired. Next, provide the Provider’s Name and Recipient’s Name along with their respective addresses and phone numbers.
- Indicate your preferred Request Delivery method by selecting either Paper Copy, Email, or Electronic Media. If you choose Email, ensure you enter a legible email address.
- Specify when this authorization will expire by filling in either a date or an event in the designated area.
- In the Purpose of Disclosure section, describe what information is being requested. If applicable, indicate whether this request includes psychotherapy notes.
- Review the acknowledgment section carefully and initial to consent to the release of potentially sensitive information.
- Complete Section C by signing and dating the form. Ensure that you print your name and relationship to the patient clearly.
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