Authorization to release medical information - Salem Clinic 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal details in the 'Patient Name', 'Birth Date', and 'Social Security # (Last 4 Digits)' fields. Ensure accuracy for a smooth processing.
3. Select the reason for your request by checking the appropriate box, such as 'Personal', 'Medical Care', or 'Benefits'.
4. Fill in your current address and contact numbers, including both daytime and cell phone numbers.
5. In the section labeled 'I AUTHORIZE INFORMATION RELEASE FROM:', provide the name and address of the facility or provider sending your information.
6. Next, complete the 'INFORMATION TO BE RELEASED TO:' section with details of the facility or provider receiving your information.
7. Specify the type of information you wish to be released by checking relevant boxes, such as 'Chart Notes' or 'Laboratory Results'.
8. If applicable, initial next to any protected or sensitive information types that may be included in your request.
9. Finally, sign and date the form at the bottom, ensuring that you print your name and indicate your relationship to the patient if necessary.

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