Atrium Health Release Of Information Form 2025

1. Click ‘Get Form’ to open the Atrium Health Release Of Information Form in the editor.
2. Begin by entering your Medical Record Number (MRN) at the top of the form. This is essential for identifying your records.
3. In the section labeled 'Authorization', list the name and address of the person or party to whom you are authorizing the release of your medical information.
4. Select the purpose for this request by checking one or more boxes, such as 'Continuity of Care' or 'Insurance Claim'.
5. Fill in your personal details, including your name when treated, date of birth, address, and contact numbers. Optionally, include the last four digits of your Social Security Number.
6. Indicate where you received treatment by circling the appropriate facility from the provided options.
7. Specify which dates of service you wish to release and select any relevant records from the list provided.
8. Choose how you would like to receive this information—via secure email, flash drive, CD, or other methods.
9. Finally, sign and date the form. If someone else is signing on your behalf, ensure that legal documentation is attached.

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