The application - Holy Cross Hospital 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter your full name, medical record number, current address, city, state, zip code, email, and phone number.
3. In the Release Information From section, check all applicable boxes and provide your date of birth.
4. For Release Information To, specify the name of the recipient (Holy Cross Hospital) and their address. Include the facility details if necessary.
5. Indicate whether you prefer paper or secure electronic delivery for your records. If choosing electronic delivery, provide the recipient's email address.
6. Clearly state the purpose for disclosure and fill in the dates of service you wish to release.
7. Review the authorization statement carefully. Sign and date at the bottom of the form. If someone other than yourself is signing, ensure legal documentation is attached.

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