Hoag medical records form 2025

1. Click ‘Get Form’ to open the Hoag Medical Records Form in the editor.
2. Begin by entering your Patient Name and Date of Birth in the designated fields. This information is crucial for identifying your medical records.
3. In the 'Use of Disclosure' section, specify the person or organization authorized to receive your information. Fill in their Name/Organization, Address, City, State, Zip, and Phone number.
4. Select how you would like to receive your requested media by checking either 'Paper' or 'CD'. If someone else will pick it up, provide their name and phone number.
5. Indicate whether this authorization applies to all health information or only specific records by checking the appropriate box. If selecting specific records, list them along with the Date of Service.
6. If applicable, check any boxes for sensitive information that you specifically authorize for release.
7. Complete the purpose for use/disclosure section and set an expiration date for this authorization.
8. Finally, sign and date the form at the bottom. If signed by someone other than yourself, indicate their legal relationship to you.

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