Edward Elmhurst Health AUTHORIZATION TO USE AND 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter your legal name, date of birth, address, and telephone number. Ensure that you provide approximate dates of treatment.
3. In the Authorization section, check the boxes for the specific health information you wish to disclose. This may include records like Emergency Records or Lab Reports.
4. Identify the entity from which your health information will be released by checking the appropriate box under 'Authorized to Release (FROM)'. If necessary, write in any additional facility names.
5. Next, specify who will receive your health information in the 'Authorized to Receive (TO)' section. Fill in their name, relationship, and contact details.
6. Indicate the purpose of disclosure and select your preferred method of disclosure from the options provided.
7. Finally, review all sections for accuracy before signing and dating the form at the bottom. Ensure that any required witness signatures are also obtained.

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