I request Northwest ENT and Allergy Center to release the 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'Patient Name' field, followed by your date of birth, social security number, and driver's license number including the state.
3. Fill in your address details in the 'Patient Address' section. If necessary, provide additional address information in the 'Patient Address cont.' field.
4. In the section labeled 'I request Northwest ENT and Allergy Center to release the following information:', check all applicable boxes for the types of records you wish to obtain.
5. Indicate whether you are directing this information to be released from or to a specific person or entity by checking the appropriate box and filling out their contact details.
6. Select your preferred method of receiving the records: Pick-up, U.S. Mail, or Fax.
7. Sign and date the form at the bottom as either the patient or an authorized representative, ensuring that you also print your name and relationship to the patient if applicable.

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