Nashville Health Information Management Service Center (HSC) Release of Information Release of Infor 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, where you must complete all fields. Enter the Patient Name, Birth Date, and the last four digits of the SSN if desired. Fill in the Facility Name and Recipient’s details including their Name and Phone number.
3. Provide the Facility Address along with your Email, City, State, and Zip code. Specify the expiration date for this authorization and indicate the purpose of disclosure.
4. Select your preferred Request Delivery method: Paper Copy, Electronic Media, or Email options. Be aware of potential risks associated with unencrypted electronic delivery.
5. In the next section, check all applicable items regarding PHI that you wish to disclose. If applicable, initial to consent to release sensitive information.
6. Review Section C for signatures. Sign and date the form as either the Patient or their Representative and print your name along with your relationship to the patient.

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