Records release pdf 2026

1. Click ‘Get Form’ to open the records release PDF in the editor.
2. Begin by filling in your personal details. Enter your name, date of birth (DOB), medical record number (MRN), email, address, city, phone number, and the last four digits of your Social Security Number (SSN).
3. Specify the approximate dates of treatment you wish to disclose. This helps ensure that only relevant information is shared.
4. Select the healthcare provider(s) authorized to disclose your information by checking the appropriate boxes. You can also specify any additional providers if necessary.
5. Indicate what specific information you want disclosed by circling your selections from options like clinic notes, lab reports, or other relevant documents.
6. Choose how you would like to receive your records—options include paper format, thumb drive, CD ROM, or via MyChart/email.
7. Fill in recipient information for those who will receive your patient information. Include their name, relationship to you, and contact details.
8. State the purpose for disclosing your records by writing it down or selecting from provided options such as personal use or continuing care.
9. Review the authorization expiration terms and select one before signing at the bottom of the form. Ensure all required signatures are completed.

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