REQUEST FOR AND AUTHORIZATION TO RELEASE 2026

1. Click ‘Get Form’ to open the REQUEST FOR AND AUTHORIZATION TO RELEASE in the editor.
2. Begin by filling in your personal information in the PATIENT INFORMATION section, including your name, last four digits of your Social Security Number, address, and date of birth.
3. In the 'Release records FROM' section, provide the required details of the person or organization releasing your records, including their name, contact number, address, and fax number.
4. Next, complete the 'Send records TO' section with similar details for the recipient. Use an office stamp if applicable.
5. Select your preferred method for sending records: Fax, Mail, or E-mail.
6. Indicate which type of information you wish to disclose by checking the appropriate boxes. Be sure to include any relevant dates where necessary.
7. If applicable, authorize the release of sensitive information by checking the corresponding boxes.
8. Specify the period for which this authorization is valid by filling in dates or selecting 'All past, present, and future periods.'
9. Review all sections carefully before signing and dating at the bottom. Ensure you select who is signing (Patient, Legal Guardian, Proxy).

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