Swedish Urology Group, PC 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name in the designated field. This is essential for identifying your healthcare information.
3. Next, fill in your Date of Birth (DOB) to further verify your identity.
4. If applicable, provide any Previous Name you may have used for medical records.
5. In the section requesting authorization details, specify the Provider’s Name and their contact information including Street Address, City, State Zip, and Phone number.
6. Select the types of healthcare information you wish to disclose by checking the appropriate boxes. You can choose to release all records or specify certain items and dates.
7. Indicate if you authorize disclosure regarding sensitive health issues by checking relevant boxes.
8. Set an expiration date for this authorization by selecting one of the options provided.
9. Finally, sign and date the form at the bottom. If someone is signing on your behalf, ensure they print their name and indicate their relationship to you.

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