CARDIOLOGY ASSOCIATES PA AUTHORIZATION 2025

1. Click ‘Get Form’ to open the CARDIOLOGY ASSOCIATES PA AUTHORIZATION in our editor.
2. Begin by filling out the 'Patient Information' section. Enter your full name, any other names you may have, address, date of birth, city, state, zip code, and phone number.
3. In the 'Release Information To' section, provide a valid email address for record delivery. Ensure it is legible as this will be used to send your health records.
4. Complete the 'Name/Facility' field with the recipient's details and specify the purpose of your request by checking one of the options provided.
5. Indicate what information you wish to be released by selecting from the options available. If unsure, a one-year abstract will be provided by default.
6. Read and acknowledge the authorization statement regarding protected health information. Initial where indicated and specify an expiration date if desired.
7. Finally, sign and date the form at the bottom to complete your authorization request.

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