Medical Records Release Authorization Form (English) 2025

1. Click ‘Get Form’ to open the Medical Records Release Authorization Form in the editor.
2. Begin by filling in your personal information. Enter your name, street address, city/state, zip code, and telephone number in the designated fields.
3. Specify the entity authorized to release your medical information by checking either 'MarinHealth Medical Center' or 'Other' and providing details if necessary.
4. Indicate the specific health information you wish to disclose by checking the appropriate boxes for items such as Emergency Room visits, Lab Results, or other relevant documents.
5. If applicable, initial next to any sensitive information you authorize for release, such as mental health treatment or HIV test results.
6. Select the purpose of this release by checking one or more options like 'Personal Copy' or 'Insurance'.
7. Fill in the expiration date for this authorization. If left blank, it will automatically expire 12 months after signing.
8. Sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship and print their name.

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