ADM010 - Release of Information Authorization - DMG - new proposal 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1: Patient Information. Fill in all fields, including your first name, last name, date of birth, address, city/state/ZIP, and phone number.
3. Move to Section 2: Information Requested. Check all relevant boxes for the type of information you wish to disclose. Be specific about the records needed and include treatment dates if applicable.
4. In Section 3, provide the name and contact details of the individual or organization authorized to receive your records.
5. Select your preferred Method of Delivery in Section 4. Options include fax, U.S. mail, secure e-delivery via email, or call for pickup.
6. Complete Section 5 by indicating the Purpose of Disclosure by checking the appropriate box.
7. Finally, sign and date the form in Section 6. Ensure that any required witness signatures are also included where necessary.

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