Mail Records - San Antonio Community Hospital - sach 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the individual's name in the designated fields for Last, First, and Middle names.
3. Fill in the home address, ensuring to include city, state, and zip code.
4. Provide the home telephone number and date of birth in their respective fields.
5. Enter the social security number as required.
6. Indicate the dates of services relevant to your health information request.
7. Select any applicable service types such as Outpatient Services, Emergency Room, or Inpatient by checking the corresponding boxes.
8. Specify the recipient's name and address where your health information will be sent.
9. Choose the purpose for which you are authorizing disclosure by checking appropriate boxes.
10. Sign and date the form at the bottom to complete your authorization.

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