Nashville health information management service center 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A. Fill in the Patient Name, Birth Date, Provider’s Name, and Recipient’s Name. Ensure all fields are accurately completed for authorization.
3. Provide the Provider’s Address, Patient Email, and optional Social Security Number. Include the Recipient’s Phone and Address details as well.
4. Specify the expiration date of the authorization and the purpose of disclosure. Indicate if this request includes psychotherapy notes by checking 'Yes' or 'No'.
5. In the next part, check all applicable hospitals from which records should be released. Be thorough in selecting all relevant options.
6. Review the acknowledgment section regarding consent for information release and initial where indicated.
7. Complete Section C by signing and dating the form. Print your name and indicate your relationship to the patient if applicable.

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