To be sent 2026

1. Click ‘Get Form’ to open it in the editor.
2. Complete the Patient Information section by entering your name, previous last name (if applicable), address, date of birth, and contact details. Ensure all information is printed legibly.
3. In the 'Who has the information you want released?' section, specify the healthcare provider or facility from which you are requesting records. Include as much detail as possible.
4. Indicate where you want the information sent in the 'Where do you want the information sent?' section. Provide complete details for accurate delivery.
5. Select what information you need in the 'Information to be sent' section. You can choose from categories like clinic visits or individual documents based on your needs.
6. If applicable, check any special permissions required for sensitive records in the 'Special Permissions' section.
7. Specify the purpose for releasing your health information in the 'Purpose for Release' section to assist with processing.
8. Choose your preferred release method (e.g., mail, fax, pick up) and provide any necessary dates or email addresses if opting for electronic delivery.
9. Finally, sign and date the authorization at the bottom of the form. If someone else is signing on your behalf, indicate their relationship and authority.

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