Mail or fax to: Release of Information, 8101 W Sam-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A. Fill in the required fields including Patient Name, Date of Birth, Provider’s Name, and Recipient’s Name. Ensure accuracy as this information is crucial for processing your request.
3. Complete the contact details for both the patient and recipient, including phone numbers and addresses. This ensures that all parties can be reached if necessary.
4. Select your preferred method of request delivery. Options include Paper Copy or Electronic Media. If you choose electronic delivery, provide a legible email address.
5. Indicate the expiration date for this authorization or an event that will trigger its expiration. If left blank, it will be valid for one year from the date of signature.
6. In Section C, ensure you sign and date the form. If applicable, include the name and relationship of a representative signing on behalf of the patient.

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