A Statewide Assessment of Sexual Harassment and Assault 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, date of birth, and patient identification number. Ensure accuracy for proper processing.
3. In the 'Authorization for Release of Protected Health Information' section, specify the name of the person or facility that will receive your health information. Include their address and contact number.
4. Select the type of records you wish to release by checking the appropriate boxes, such as medical records or mental health information.
5. Indicate the specific date or time period for which you are requesting information. This helps narrow down the records needed.
6. Review your rights regarding this authorization and ensure you understand that it is voluntary. You may revoke it at any time by submitting a written request.
7. Finally, sign and date the form at the bottom. If applicable, include your relationship to the patient if you are not signing on your own behalf.

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