Authorization - Release Of Medical Records Information 2025

1. Click ‘Get Form’ to open the Authorization - Release Of Medical Records Information in the editor.
2. Begin by filling in your personal details in the 'Patient Identification' section, including your name, date of birth, address, and last four digits of your Social Security Number.
3. In the 'Provider' section, enter the name and contact information of the individual or organization that will be releasing your medical records.
4. Specify where you want the information sent by completing the 'Disclose Information to' section with the recipient's details.
5. Select the type of information you wish to disclose from the options provided, such as standard chart copy or specific reports.
6. Indicate service dates for which records are requested and choose a preferred format for receiving them (e.g., email, paper).
7. If applicable, check the box for substance abuse documentation and provide an expiration date for this authorization.
8. Finally, sign and date the form at the bottom. If signed by a legal representative, include their relationship to you.

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