AUTHORIZATION TO RELEASE - Baptist Health 2026

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

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