Authorization for release of Protected Health Information (PHI) - North Florida Regional Medical Cen 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, filling in your *Patient Name*, *Date of Birth*, and *Provider’s Name* as North Florida Regional Medical Center. Ensure all required fields are completed.
3. Next, provide the *Recipient’s Name* and their contact details including *Address*, *City*, *State*, and *Zip*. Choose your preferred delivery method for the PHI.
4. Indicate the purpose of disclosure and describe the information you wish to be released. If applicable, specify if this request includes psychotherapy notes.
5. Review the acknowledgment section regarding consent for sensitive information. Initial where indicated.
6. Complete Section C by signing and dating the form. If applicable, include your representative's name and relationship to you.

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