Subject to the statements printed on the back, I, the undersigned patient or legal representative, h 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your MR# and Date Completed at the top of the form. This helps in tracking your request.
3. Fill in your Patient Name and Date of Birth accurately to ensure proper identification.
4. In the section labeled 'I authorize', specify who is authorized to disclose or obtain health information and provide their facility name and address.
5. Select your preferred Method of Disclosure/obtain by checking the appropriate boxes such as Mail, Verbal, or Electronic.
6. Indicate the types of information you wish to disclose by checking relevant options like Reproductive Healthcare Services or Mental Health Record.
7. Complete the purpose of disclosure if applicable, and set an expiration date for this authorization.
8. Finally, sign and date the form at the bottom. If you're a legal representative, ensure you attach documentation verifying your authority.

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