Photocopy or facsimile of the original authorization will be considered as valid as the original 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and any previous names associated with them in the designated field.
3. Fill in the date of birth or medical record number to uniquely identify the patient.
4. Provide the patient's street address, city, state, and ZIP code for accurate identification.
5. In the 'Authorizes' section, specify who is releasing the information and who will receive it by filling in their names and addresses.
6. Select all types of information to be released by checking the appropriate boxes, ensuring you include any specific reports or records needed.
7. Indicate the reason for disclosure by selecting from options provided or writing a brief explanation if necessary.
8. Review your rights regarding this authorization, ensuring you understand your ability to inspect, copy, refuse, or withdraw consent.
9. Finally, sign and date the form. If signed by a representative, indicate their relationship to the patient.

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