Open Eng - University of Illinois at Chicago - uic 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the form. This identifies you as the participant authorizing the release of medical information.
3. In the next section, specify the name or organization that you are authorizing to release your medical information. Ensure this is accurate to avoid any delays.
4. Fill in the recipient's details where indicated, including their name and address. This is crucial for ensuring that your information reaches the correct party.
5. Review the purpose of this authorization, which is to evaluate your diabetes management program. Make sure you understand how your data will be used.
6. Sign and date the form at the bottom. This confirms your consent and activates the authorization for one year unless revoked earlier.
7. Finally, ensure you have a copy of this authorization request for your records, as stated in the acknowledgment section.

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