Medical Records Consent Form - Fayetteville Otolaryngology 2026

1. Click ‘Get Form’ to open the Medical Records Consent Form in our editor.
2. Begin by filling out the Patient Demographic Information section. Enter your name, last four digits of your Social Security number, date of request, and date of birth.
3. Select the reason for release by circling one option: hospital, personal, attorney, or physician. This helps clarify the purpose of your request.
4. In Option #1, indicate if you want to release your health information to Fayetteville Otolaryngology. If applicable, provide details about any sensitive information that may be included.
5. For Option #2, specify whether you wish to view your protected health information or obtain a copy. If obtaining a copy, choose your preferred delivery method and note any specific items needed.
6. Finally, sign the form at the bottom to authorize the release of your health information and ensure all fields are completed before submitting it.

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