Medical release health information form 2026

1. Click ‘Get Form’ to open the medical release health information form in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your last name, first name, middle name, current address, maiden or other names, city, state, zip code, social security number, date of birth, phone number, and email address.
3. In the 'Reason Needed' section, specify the purpose of your request by checking the appropriate box (e.g., personal, medical treatment).
4. Next, indicate 'Information to be Disclosed From' by selecting applicable options such as The MetroHealth System or other specified sources.
5. In the 'Information Needed' section, check all relevant types of information you wish to disclose (e.g., office visits, test results).
6. Fill out the 'Release Information To' section with the recipient's name and address. Specify how you want the information delivered (e.g., mail or secure electronic delivery).
7. Finally, sign and date the authorization at the bottom of the form. If someone else is signing on your behalf, include their relationship to you.

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