Repository eiu healthAuthorization toAuthorization to Release Patient Information 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth, and Address in the designated fields. Ensure all information is printed clearly.
3. In section 1, specify the recipient of your medical records by filling in their Name and Address. This is crucial for ensuring your records are sent to the correct location.
4. For section 2, indicate the dates of treatment you wish to disclose. If exact dates are unknown, provide an approximate time frame.
5. Select the specific information you want disclosed in section 3 by checking the appropriate boxes for each type of record.
6. In section 4, choose the purpose of disclosure from the options provided. This helps clarify why you are requesting your records.
7. Decide how you would like your records delivered in section 5. Options include paper delivery, faxing, or electronic methods.
8. Review section 6 regarding sensitive information and indicate if there are any details you do not wish to release.
9. Complete sections 7 and 8 by signing and dating the form. If applicable, include details about your legal guardian or representative.

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