Fenway Health Authorization for Disclosure of Protected 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter your full name, any alternate names, date of birth, address, phone number, and email address. Select your preferred method of contact for medical records.
3. In the next section, provide details about the sender or facility releasing your protected health information. Fill in the name, phone number, address, and fax number.
4. Then, specify the recipient or facility that will receive your information by entering their name, phone number, address, and fax number.
5. Select the reason for release from the options provided. You can choose multiple reasons if applicable.
6. Indicate which specific information you wish to disclose by selecting from the list provided. Be sure to include any relevant dates if necessary.
7. Review sensitive information disclosure options and initial next to each type of record you want released.
8. Finally, sign and date the authorization at the bottom of the form. Ensure all sections are completed to avoid processing delays.

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