Medical Records Release form - The University of Tennessee ... - utmedicalcenter 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the individual authorized to release information in the designated field.
3. Fill in the patient's name and date of birth accurately to ensure proper identification.
4. Provide the patient's address and telephone number, along with their Social Security Number for verification purposes.
5. Specify the period of health care you wish to cover by filling in the start and end dates.
6. Select which medical records you want released by checking the appropriate boxes, such as 'Complete Medical Record(s)' or 'Laboratory Test'.
7. Indicate the purpose for which this information will be used, ensuring clarity on your intent.
8. Enter the recipient's name and address where the information should be sent.
9. Sign and date the authorization at the bottom of the form, ensuring all fields are completed before submission.

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