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AUTHORIZATION TO RELEASE - Baptist Health 2026
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How to use or fill out AUTHORIZATION TO RELEASE - Baptist Health
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the 'Who is Releasing Information' section. Select the appropriate Baptist facility and provide their address, fax number, and phone number.
- In the 'To Whom Information Will Be Provided' section, enter the recipient's details including their name, address, fax number, and telephone number.
- Complete your personal information by entering your name, birth date, medical record number, address, city, state, zip code, and telephone number.
- Indicate if you would like to enroll in the My Baptist Connect patient portal by selecting 'Yes', 'Decline', or 'Previously Enrolled'.
- Select the records being released by checking the relevant boxes for each type of record needed.
- Specify the dates of service required or select 'All' or 'Last Visit Only'.
- Choose the purpose of release from the provided options and fill in any additional details as necessary.
- Sign and date the form at the bottom. If applicable, have a representative sign on your behalf.
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