Authorization to Disclose Release Protected Health Information 2025

1. Click ‘Get Form’ to open the Authorization to Disclose Release Protected Health Information in the editor.
2. Begin by entering the Patient Name, Date of Birth, Phone, and Address in the designated fields. Ensure all information is accurate for proper identification.
3. In the Recipient section, fill in the Name, Phone, Fax, and Address/Email of the individual or entity receiving the health information. This ensures that your records are sent to the correct destination.
4. Select whether you want to send the entire medical record or only specific information. If choosing specific information, clearly indicate what records are needed and for which dates.
5. Indicate the purpose for requesting this information by checking one of the options provided: Continuation of care, Personal use, or Other. If selecting 'Other', describe your reason.
6. Review any sensitive information that may be included in your medical records. Check any boxes next to types of information you wish to exclude from disclosure.
7. Sign and date the form at the bottom. If applicable, have a witness sign as well if releasing sensitive records.

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