5959 Park Avenue-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and address in the designated fields. Ensure accuracy as this information is crucial for processing your request.
3. Fill in the phone number and last four digits of the Social Security Number. This helps verify identity and expedite the release process.
4. Select the specific health information you wish to request by checking the appropriate boxes. You can choose multiple options based on your needs.
5. Indicate the dates of service for which you are requesting information. Only list those dates that are authorized for release.
6. Complete the section authorizing Saint Francis Hospital to release your PHI by providing the name, phone number, and address of the recipient.
7. Sign and date the authorization at the bottom of the form. If applicable, indicate your relationship or authority to act on behalf of the patient.

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