RELEASE OF MEDICAL INFORMATION AUTHORIZATION 2025

1. Click ‘Get Form’ to open the RELEASE OF MEDICAL INFORMATION AUTHORIZATION in the editor.
2. Begin by entering your Patient Name and Local Phone number at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in your Date of Birth and Dawg Tag #, which helps in verifying your identity and records.
4. Specify the entities you are releasing information from and to by filling in the 'Release From' and 'Release To' sections, including names, addresses, and contact details.
5. Indicate the purpose of the release by checking appropriate boxes such as 'Patient’s Request', 'Legal', or 'Further Treatment'.
6. Select how you want to release information (Written, Verbal, or Both) and specify the dates of records to be released.
7. Review any exceptions regarding sensitive information like HIV or mental health records; initial where necessary.
8. Choose your preferred method of delivery (Mail, Hand Carry, Fax) for receiving the released information.
9. Finally, sign and date the authorization at the bottom of the form. If applicable, include details about your representative's authority.

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