855 764 2382-2026

1. Click ‘Get Form’ to open the 855 764 2382 document in the editor.
2. Begin with Section A, filling in your Birth Date, Social Security Number (optional), and Patient Name. Ensure accuracy as this information is crucial for identification.
3. Next, provide the Provider’s Name and Address. In this case, it will be Redmond Regional Medical Center at 501 Redmond Rd, Rome GA 30165.
4. Complete the Recipient section by entering the Name, Address, Phone Number, and Fax Number of the individual or entity receiving the records.
5. Specify the expiration date or event for this authorization. Choose a purpose for disclosure from the provided options such as Continuity of Care or Insurance.
6. Indicate what information you wish to disclose by checking appropriate boxes and providing any necessary descriptions or dates.
7. In Section C, sign and date the form. If applicable, include your Printed Name and Relationship to Patient.

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