MRN: Patient Name: AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name and MRN in the designated fields. Ensure that all information is accurate for proper identification.
3. Fill in the Address, City, State & Zip Code, Date of Birth, and Phone number. This information is crucial for verifying your identity.
4. Select the healthcare facility from which you want records released. If applicable, specify a designee who can pick up your records by filling out their name and relationship to you.
5. Indicate how you would like to receive your records (CD, E-Mail, or Paper Copy) and provide any necessary contact details such as email or phone number.
6. Specify the purpose of the release and select the type of records you wish to obtain by checking the appropriate boxes.
7. If sensitive information is required, check those boxes and specify the date/time period for this information.
8. Sign and date the authorization at the bottom of the form. If someone else is signing on your behalf, indicate their relationship to you.

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