Henry ford form 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your full name, including any previous last names, current address, city, state, zip code, date of birth, and phone number.
3. In the 'Request Information from' section, check all applicable boxes for the Henry Ford facilities you wish to authorize access to.
4. Next, specify the recipient of the information in the 'Release (disclose) Information to' section. Provide their name, phone number, address, and fax number.
5. Indicate which medical records you want included by checking the relevant boxes under 'Check box(s) below if you want to include medical records for these services.'
6. Complete any additional sections as required and ensure you sign and date at the bottom of the form before submitting.

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