FAIRFIELD MEMORIAL HOSPITAL HORIZON HEALTHCARE 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name, date of birth (DOB), and medical record number (MR#) in the designated fields.
3. Fill in the patient's address completely to ensure accurate communication.
4. Select the information you wish to be released by checking the appropriate boxes, such as discharge summary or lab results.
5. Specify treatment dates for which records are being requested by filling in the 'from' and 'to' fields.
6. Indicate the purpose of disclosure by checking relevant boxes like continuity of care or insurance.
7. Complete the release sections, including details about where to send the information, ensuring all contact details are accurate.
8. Review each item regarding understanding and initial where required before signing and dating the form.

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