Swedish Urology Group, PC 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for your healthcare records.
3. If applicable, provide your Previous Name to assist in locating your medical history.
4. In the section requesting authorization for release, fill in the Provider’s Name, Street Address, City, State Zip, and Phone number where you want your information sent.
5. Select the types of healthcare information you wish to disclose by checking the appropriate boxes. You can choose all records or specify certain items and dates.
6. Indicate if you authorize disclosure regarding specific health conditions by checking relevant boxes.
7. Specify when this authorization ends by selecting one of the options provided.
8. Finally, sign and date the form at the bottom. If signing on behalf of someone else, include your printed name and relationship.

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