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The document is an authorization form for the release of confidential medical information from Boca Raton Regional Hospital. It allows patients to specify what records they wish to obtain, the format for receiving them, and includes details about fees associated with different formats. The form emphasizes patient rights regarding the disclosure of their health information and outlines the process for revoking authorization.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name, Last 4 digits of the Social Security Number, Date of Birth, and Medical Record Number in the designated fields.
Provide the Patient's Phone Number and Email address to ensure proper communication.
In the authorization section, specify which records you wish to release by filling out the recipient's name and address.
Select your preferred format for receiving records: Email, Paper Records, or CD. Be aware of any associated fees listed in the form.
Indicate if you will be picking up your medical records by checking the appropriate box.
Clearly disclose the exact information you want released by filling out any relevant sections regarding specific reports or date ranges.
Finally, sign and date the form at the bottom, ensuring that all required fields are completed before submission.

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