8048 Auth for Use or Disclosure of Health InforIncoming Records 090220 DRAFT-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name and date of birth in the designated fields at the top of the form.
3. In the 'Use of disclosure' section, provide the name or organization that will be releasing your records, along with their contact details including address, city, state, zip code, phone number, and fax number.
4. Specify who will receive your records by filling in 'Hoag Health Information' and their contact information as listed.
5. Indicate which specific records you are authorizing for release by checking the appropriate boxes and providing any necessary dates of service.
6. Select the purpose for this authorization from the options provided or specify another reason if applicable.
7. Sign and date the form at the bottom. If someone other than the patient is signing, indicate their relationship to the patient.

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