Upon completion, please send this form to: In regards to 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Client name' and 'Client ID or SSN' in the designated fields at the top of the form.
3. In section 1, specify the person or organization authorized to provide your health information. Ensure you include all relevant names.
4. For section 2, indicate the person or organization authorized to receive and use your information. Be precise to avoid any confusion.
5. In section 3, provide a detailed description of the information you wish to disclose. Include specific dates and types of information as required.
6. State the purpose of your request in section 4. If you prefer not to specify, simply write 'At the request of the individual.'
7. Review sections 5 through 9 carefully, ensuring you understand your rights regarding revocation and expiration of this authorization.
8. Finally, sign and date the form at the bottom before submitting it as instructed.

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