Authorization for Release of Medical Information - Conroe 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient's address, including city, state, and zip code. This helps in ensuring that all communications are directed correctly.
4. Provide the patient's Social Security number and phone number. This information may be required for verification purposes.
5. Indicate the date of request and when the information is needed by filling out those respective fields.
6. Authorize Perri Dermatology, PLLC to release or obtain information by filling in the names and addresses of providers or facilities involved.
7. Select the purpose for this request by checking one of the options provided, such as 'Specialist' or 'Transfer'.
8. Specify the type of records requested by checking either 'All medical records' or detailing specific parts of your medical record.
9. Review your entries for accuracy before signing at the bottom. Ensure you understand your rights regarding this authorization.

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