Chen release form 2026

1. Click ‘Get Form’ to open the chen release form in our editor.
2. Begin by filling in your personal information. Enter your first name, last name, maiden name, date of birth (DOB), social security number (SSN), and phone number in the designated fields.
3. Provide your address details including street address, city, state, and zip code.
4. Select one of the authorization options: either authorizing another party to release records to ALC or authorizing ALC to release records to another party or yourself.
5. Fill in the details of the doctor and facility from which you are requesting records. Ensure you include the doctor's name, facility name, address, city, state, zip code, phone number, and fax number.
6. Indicate which documents you would like disclosed by circling all applicable options such as Entire File, History & Physical, Progress Notes, Lab/Test Results, or Other.
7. Circle the reason for disclosure from options like Changing Physicians or Continuing Care.
8. If leaving the practice, provide a brief explanation for your departure.
9. Review the confidentiality notice and charges associated with printing records before signing at the bottom of the form. Ensure you date your signature.

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