OFFICE ONLY: Date Recd: Date Sent: Preview on Page 1

OFFICE ONLY: Date Recd: Date Sent: 2026

The document is an authorization form for the release of confidential health information from a healthcare provider. It allows patients to specify which records they wish to be released, including complete chart records, lab reports, and billing information. The form requires patient identification details and outlines the purpose of the release, as well as legal considerations regarding consent for minors. It emphasizes the patient's right to revoke authorization and informs them about potential charges for record requests.

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

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Can I sign my OFFICE ONLY: Date Recd: Date Sent: in electronic format?

Based on eSignature laws, documents signed electronically have the same validity as traditionally approved ones. You can eSign almost any business and private paperwork. Four types of paperwork still call for wet signatures only - wills and testamentary trusts, court orders and other court forms, state statutes governing divorce, adoption, or other family law, and notice of cancellation of utility services. If you adhere to the rules and use a secure and compliant software solution, like DocHub, you can eSign your OFFICE ONLY: Date Recd: Date Sent: without printing it.

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