HIPAA Medical Record Release Auth Form docx 2025

1. Click ‘Get Form’ to open the HIPAA Medical Record Release Auth Form in our platform.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient's address, telephone number, and a parent's contact number if applicable. This helps maintain clear communication regarding the request.
4. In the authorization section, specify who may receive the medical records by providing their name and complete address.
5. Indicate the dates of records you wish to be sent by checking either 'Most recent two (2) years' or specifying 'Specific dates of service'.
6. If applicable, sign where indicated to authorize disclosure of sensitive information. Remember, any patient aged 14 and over must provide their signature.
7. Complete the reason for request section and provide your signature if you are 18 years or older. If signing on behalf of a minor, include your relationship or authority.
8. Finally, review all entered information for accuracy before submitting your request through our editor.

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