Legacy health form 2025

1. Click ‘Get Form’ to open the legacy health form in the editor.
2. Begin by entering the patient's last name, first name, and any nicknames or maiden names in the designated fields.
3. Fill in the birth date and middle name of the patient, ensuring accuracy for identification purposes.
4. Provide a telephone number and indicate whether it is okay to leave a detailed message by selecting 'Yes' or 'No'.
5. Complete the patient's mailing address, including street address, city, state, and zip code.
6. Identify the health care provider releasing information by entering their name and contact details.
7. Specify the person or agency receiving this information by filling in their name and address.
8. Clearly state the purpose of release and select whether you authorize disclosure of the entire medical record or specific documents.
9. Initial next to any items that must be released, such as HIV results or mental health records, as required.
10. Sign and date the form at the bottom. If someone other than the patient is signing, include their relationship to the patient.

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