M3132 2026

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4.8 out of 5

155 votes

The document is an 'Authorization for Release of Information' form used by Duke Health, allowing patients to authorize the release of their medical records to specified individuals or entities. It includes sections for patient information, recipient details, types of information to be released, purpose of the request, delivery format, and consent regarding sensitive information. The form emphasizes patient rights regarding revocation and privacy.

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Click ‘Get Form’ to open the m3132 in the editor.
Begin with Part A: Patient Information. Fill in your name, phone number, email, address, date of birth, last four digits of your SS#, and medical record number.
Move to Part B: Person or Company Who Will Receive Information. Indicate if it’s yourself or another entity by filling in their details.
In Part C: Information to be Released, check the appropriate boxes for treatment dates and specific records you wish to include.
Proceed to Part D: Purpose of Request. Select the reason for your request from the options provided.
In Part E: Format and Delivery of Information, choose how you would like to receive the information.
Complete Part F: Review and Approval by signing and dating the form. Ensure all sensitive information is marked as needed.
If applicable, fill out Part G: Witness section and attach any necessary documentation before submission.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (155 Votes)
2012	4 Satisfied (40 Votes)

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M3132 2026

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