Authorization use health information form 2026

1. Click ‘Get Form’ to open the authorization use health information form in the editor.
2. Begin by entering the date at the top of the form, followed by the patient's last name, first name, and middle initial. Fill in their address, telephone number, city/state, zip code, and optional SSN.
3. Identify the individual or organization authorized to make the disclosure by filling in their last name or entity, first name, middle initial, address, city/state, telephone number, and zip code.
4. Next, specify who may receive this information by completing the same fields for the recipient as you did for the disclosing party.
5. Indicate treatment dates and purpose of request clearly. Then check all applicable boxes regarding what specific health information is to be disclosed.
6. Review sections on sensitive information and rights. Specify an expiration date if desired; otherwise, it will default to one year from signing.
7. Finally, sign and date at the bottom of the form. If signed by a legal representative, include their relationship to the individual.

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