Authorization to Release Information We are committed to ...: Fill out & sign online

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Click ‘Get Form’ to open the Authorization to Release Information form in the editor.
Begin by filling in the individual’s name and address, ensuring all fields are completed accurately for proper identification.
Select the records you wish to be released by checking the appropriate boxes. You can choose from options like 'All Healthcare' or specify 'Other' if needed.
Indicate any limitations on the information being released by specifying dates or types of information in the provided section.
Complete the authorization section by selecting whether you want your information released or obtained, and provide payee details including name, address, and phone number.
If opting for email transmission, print your email address clearly and acknowledge the risks associated with sending sensitive information via email.
Review and initial any specific types of records you agree to disclose, such as mental health treatment or HIV status.
Finally, sign and date the form at the bottom. Ensure that you understand your rights regarding revocation and confidentiality before submitting.

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