OFFICE ONLY: Date Recd: Date Sent: 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Locate the 'Date Recd' field and enter the date you received the document in the format MM/DD/YYYY.
  3. Next, find the 'Date Sent' field and input the date you sent the document, also in MM/DD/YYYY format.
  4. Proceed to fill out the authorization section by selecting the appropriate options for releasing health information.
  5. Complete all required fields, including your name, date of birth, and social security number as prompted.
  6. Review your entries for accuracy before finalizing your form. Ensure all necessary checkboxes are selected based on your preferences.

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