VALLE VISTA HEALTH SYSTEM 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, date of birth, and social security number in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the address and phone number of the patient. This helps in maintaining communication regarding their health records.
4. Specify the recipient's details by entering their name, relationship to the patient, address, and contact numbers. This section is vital for ensuring that records are sent to the correct individual or organization.
5. Indicate the dates of treatment that you wish to authorize for disclosure. This helps limit the information shared to relevant timeframes.
6. Select which specific records you want to be disclosed by checking the appropriate boxes. Be mindful of including sensitive information such as psychiatric evaluations or substance abuse records if applicable.
7. Choose your preferred method of delivery for the requested records: mail, pick-up, or electronic delivery. If opting for electronic delivery, provide a valid email address.
8. Review all entered information for accuracy before signing. Ensure that you understand your rights regarding this authorization and any associated charges.

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