BC 4761 Authorization to Use or Disclose Protected Health Information (ENGLISH)-2026

1. Click ‘Get Form’ to open the BC 4761 Authorization form in the editor.
2. Begin by filling out the Patient Information section. Enter your first name, middle initial, last name, and any previous names used at the time of treatment. Include your date of birth, phone number, street address, city, state, and zip code.
3. In the 'What records do you want?' section, check the appropriate boxes for the types of records you wish to disclose. Specify any additional details as needed.
4. Indicate the purpose for which you are authorizing this disclosure in the provided space. Fill in the date(s) of service if applicable.
5. Choose how you would like your records delivered: paper mail, CD, in-person pickup, or electronically via a patient portal.
6. Complete the section detailing where you want the information sent by providing a name, phone number, mailing address, and fax number if necessary.
7. Finally, sign and date the authorization at the bottom of the form. Ensure that all required fields are completed before submitting.

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