Authorization form 2026

1. Click ‘Get Form’ to open the authorization form in the editor.
2. Begin by entering the name and address of your physical therapist or provider in the designated field. This information is crucial for identifying who will disclose your health information.
3. Next, specify the health information you authorize to be disclosed by checking the relevant boxes, such as 'Diagnosis or referral by a practitioner' and 'Medical history'. Ensure all applicable sections are completed.
4. Provide the complete mailing address of the Oregon Physical Therapist Licensing Board where your records should be sent. This ensures that your information reaches the correct destination.
5. Fill in your personal details, including your printed name, date of birth, signature, and date. This step confirms your consent and finalizes the authorization process.

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