Pioneerphysicians patient-formsAuthorization for Use and Disclosure of Protected Health 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter your name, account number, street address, city, state, zip code, date of birth, primary phone number, alternate phone number, and email address.
3. In the Medical Records Released From section, provide the name of the clinic or provider releasing your records along with their contact information.
4. Next, complete the Recipient Information section. Fill in the name and address of the individual or organization receiving your medical records. Include their relationship to you and contact details.
5. Indicate how you would like your records delivered by selecting one of the options provided (e.g., In-Person, Mail).
6. Specify the Dates of Service you wish to disclose and state the Purpose of Disclosure clearly.
7. Select which Patient Health Information you want released by checking all applicable boxes.
8. Finally, review the authorization statement at the bottom. Sign and date it to confirm your understanding and consent.

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