Authorization for Release of Confidential Information 2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Provide the Patient's Phone Number and Email address to ensure proper communication.
4. In the authorization section, specify which records you wish to release by filling out the recipient's name and address.
5. Select your preferred format for receiving records: Email, Paper Records, or CD. Be aware of any associated fees listed in the form.
6. Indicate if you will be picking up your medical records by checking the appropriate box.
7. Clearly disclose the exact information you want released by filling out any relevant sections regarding specific reports or date ranges.
8. Finally, sign and date the form at the bottom, ensuring that all required fields are completed before submission.

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