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1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name(s) in the designated field. Ensure that you provide accurate and complete names for proper identification.
3. Fill in the Social Security Number and Date of Birth fields. This information is crucial for verifying patient identity.
4. In the 'OBTAIN FROM' section, specify the releasing facility's name and address. Similarly, complete the 'RELEASE TO' section with the receiving entity's details.
5. Select the information you wish to review by checking the appropriate boxes under 'INFORMATION TO BE REVIEWED'. You can choose options like Emergency Room Report or Discharge Summary.
6. Indicate the purpose for this release by checking one or more options provided, such as Continuity of Medical Care or Personal Use.
7. Finally, sign and date the authorization at the bottom of the form. If applicable, include your printed name and relationship to the patient.

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