Authorization for Release of Information - Colleton Medical 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, filling in your *Patient Name*, *Date of Birth*, and *Provider’s Name*. Ensure all required fields marked with an asterisk are completed.
3. Provide the *Recipient’s Name* and contact details, including phone and fax numbers. Fill in your address information accurately.
4. Select your preferred method for request delivery. If you choose electronic media, be aware of the risks associated with unencrypted formats.
5. Indicate the expiration date or event for this authorization. If left blank, it will remain valid for one year from the date of signature.
6. In the section regarding psychotherapy notes, indicate whether this request includes such notes by checking 'Yes' or 'No'.
7. Complete Section C by signing and dating the form. Ensure that you print your name and relationship to the patient if applicable.

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