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Authorization to Release Medical Record Information - Brown ... 2026
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- Click ‘Get Form’ to open the Authorization to Release Medical Record Information in the editor.
- Begin by entering your Patient Name, Former Name (if applicable), and Current Address. Ensure that all information is accurate and legible.
- Fill in your Date of Birth, Home Phone, and Work Phone. This information helps verify your identity.
- In the section labeled 'I Authorize Information Released FROM:', provide the necessary details including your Social Security Number.
- Specify where you would like your records sent by filling in the recipient's Name and Address. Be sure to include City, State, and Zip Code.
- Select the Purpose of Release from the provided options such as 'Personal use' or 'Insurance change'.
- Indicate whether you consent to faxing your medical records by selecting YES or NO.
- Choose how you would like to receive your records: via CD or Paper. If opting for a CD, ensure you have Adobe 8 or higher.
- Identify the Type of Information To Be Released. You can choose General Medical Records or specify particular information if needed.
- Review all entries for accuracy before signing and dating the form at the bottom. Remember that this authorization will expire in 180 days unless specified otherwise.
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Related links
Sep 13, 2022 The privacy interest in identifying information may be further diminished where the individual identified in the record is deceased. releaseRead more
To obtain your record, please complete and return a Student Health Records Request/Release Authorization form via email, fax or mail as instructed below. Email:Read more