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- Click ‘Get Form’ to open the Authorization for Release of Health Care Information in the editor.
- Begin by filling in your name and address in the designated fields for 'Principal Name & Address'. This identifies you as the individual granting authorization.
- Next, enter the name and address of your agent in the 'Agent Name & Address' section. This person will have authority over your health care information.
- If applicable, list any successor agents who can act on your behalf if your primary agent is unavailable. Fill in their names and addresses accordingly.
- Review the sections regarding the scope of information being released. Ensure you understand what health information is included under this authorization.
- Sign and date the form at the bottom where indicated. This signature confirms your consent for the release of your health care information.
- If required, complete the acknowledgment section with a notary public to validate your authorization.
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