PDF authorization - for use or disclosure of health information - Providence 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. This information is crucial for identifying the correct medical records.
3. Fill in the medical record number, home phone, cell phone, current address, city, state, and zip code. Ensure all details are accurate to avoid any delays.
4. In the 'Use and Disclosure of Health Information' section, indicate whether you authorize St. Mary Medical Center to release your records to yourself or another facility/person by checking the appropriate box.
5. Select your preferred delivery method (CD, paper, email) and provide the necessary contact details for where the records should be sent.
6. Specify what information you wish to be released by checking one of the options provided. Be mindful that certain requests may incur fees.
7. If applicable, authorize the release of statutorily protected information by checking and initialing as appropriate.
8. State the purpose for which you are requesting this information by selecting from the options available.
9. Finally, sign and date the form at the bottom. If signed by a representative, include their relationship to you.

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