Section A:I authorize the disclosure of my personal health information to the Persons Entities as de 2026

1. Click ‘Get Form’ to open it in the editor.
2. In the first field, enter your full name as it appears on your identification documents.
3. Next, provide your current address, ensuring that it is accurate for any correspondence related to this authorization.
4. Fill in your telephone number where you can be reached for any follow-up questions or clarifications.
5. Enter your member number if applicable; this helps identify your records with the healthcare provider.
6. Review all entered information for accuracy before proceeding to ensure a smooth processing of your request.

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