This form is to be filled out by a customer if there is a request to release the customers protected health information (PHI) to another person or 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part A: Enter your personal information, including your last name, first name, address, phone numbers, date of birth, and subscriber number. Ensure all details are accurate.
3. Move to Part B: Indicate who will receive your information by checking the appropriate boxes and providing names where required.
4. In Part C: Specify what information can be released by selecting either 'All of my information' or 'Only limited information' and check the relevant boxes.
5. Complete Part D: State the purpose for this approval by selecting an option that best describes your reason.
6. Fill out Part E: Indicate when your approval expires by choosing a duration or specifying a date/event.
7. In Part F: Choose how you would like to receive the information (paper copies, fax, digital copies, or email) and provide necessary details.
8. Finally, review and sign in Part G. Ensure you understand the implications of releasing your PHI before submitting the form.

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