Specify Information to be Disclosed: Entire Record 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, including last, first, and middle names in the designated fields.
3. Fill in the home address, city, state, zip code, and home telephone number to ensure accurate identification.
4. Specify the information to be disclosed by checking 'Entire Record' or selecting other relevant options such as 'Discharge Summary' or 'Lab Reports'.
5. Indicate the service date(s) or range for which you are requesting records in the provided space.
6. Select all applicable locations from which records will be requested by checking the corresponding boxes.
7. Review and initial any sensitive information that you authorize for release, such as STD results or mental health information.
8. Complete the recipient's details including name, phone number, fax number, and address where records should be sent.
9. Specify the purpose of authorization by checking one of the options provided.
10. Sign and date the form at the bottom to finalize your authorization.

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