Release of Information form - Bon Secours Richmond Health System 2026

1. Click ‘Get Form’ to open the Release of Information form in the editor.
2. Begin by entering the patient's full legal name, date of birth or social security number, and day phone number in the designated fields.
3. In the 'Authorize' section, specify the organization that will disclose the information. This is crucial for ensuring your records are sent to the correct entity.
4. Select which specific information you wish to disclose by checking the appropriate boxes, such as 'Entire Record', 'Operative Report', or 'Laboratory Results'.
5. Fill in the details of the person or facility receiving this information, including mailing address and phone number. If urgent care is needed, provide a fax number.
6. Indicate the purpose of disclosure by selecting from options like 'Insurance', 'Legal', or 'Personal'.
7. Review and understand the authorization statements regarding confidentiality and revocation rights before signing at the bottom of the form.

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