AUTHORIZATION TO RELEASE CLAIM HISTORY 2026

1. Click ‘Get Form’ to open the AUTHORIZATION TO RELEASE CLAIM HISTORY in the editor.
2. Begin by entering your name as the provider in the 'Type or Print Name of Provider' field. Ensure accuracy for prompt processing.
3. Fill in the 'Name of Group or Organization' and your 'Current Mailing Address' to ensure that correspondence is directed correctly.
4. Provide your 'Phone Number', 'Medical License Number', and the last four digits of your Social Security Number for identification purposes.
5. Input your 'Policy #' and 'Account #' if known, along with your NPI # to facilitate accurate reporting.
6. Specify where you want the reports sent by filling out the 'Company/Organization Name' and their corresponding mailing address.
7. Sign and date the form in the designated areas. Remember, stamped signatures are not accepted.

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