Request to Release Protected Health Information form (MOS- 02-2018)-2025

1. Click ‘Get Form’ to open the Request to Release Protected Health Information form in our editor.
2. In Section 1, enter the Patient's Full Name, Date of Birth, and Email. Ensure accuracy as this information is crucial for identification.
3. Proceed to Section 2 where you will specify the recipient of the information. Fill in their Name, Attention (if applicable), Address, ID Number, Phone, and Fax.
4. In Section 3, select the reason for releasing the information by checking the appropriate box. Options include Personal Records, Insurance, Continuation of Care, and others.
5. Section 4 requires you to indicate specific information to be released. Check all relevant boxes such as Office Notes or Test Results and provide dates of service if necessary.
6. Finally, in Section 5, choose your preferred Method of Delivery: Mail, Fax, or Pick Up. Review all entries for completeness before signing.

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