Health Information Departments (H 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth, and Street Address in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Provide your Telephone number, City, State & Zip Code. This helps in contacting you if necessary.
4. In the section that authorizes disclosure, fill in the recipient's details including Business/Department/Office and Address/E-mail/Fax of Facility.
5. Select the type of records you wish to disclose by checking the appropriate boxes such as Paper Record, Email Secured, or Direct Electronic Access.
6. Specify the purpose for releasing this information clearly in the provided space.
7. Sign and date the form at the bottom. If a personal representative is signing, ensure their authority is described.

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