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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your personal information. Fill in your name, date of birth, address, phone number, and social security number in the designated fields.
- Indicate today’s date and the date of service requested. This helps ensure that your request is processed accurately.
- Select the specific information you wish to be released by checking the appropriate boxes. Options include discharge summaries, lab results, and more.
- Provide a reason for the release of information by selecting from the options provided or specifying another reason if necessary.
- Sign the authorization section at the bottom of the form. If applicable, have your legal representative sign as well.
- Finally, choose how you would like to receive your records—via mail, fax, or pick up—and specify if you prefer paper copies or a CD.
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