Releaseforms northshore org 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, date of birth, address, and phone number.
3. In the section labeled 'I AUTHORIZE NORTHSHORE UNIVERSITY HEALTHSYSTEM TO RELEASE TO:', provide the recipient's name and relationship to you, along with their contact details.
4. Indicate how you wish to receive your records by checking the appropriate box for Disc (CD), Paper, or Secure Email. If choosing Secure Email, ensure you enter a valid email address.
5. Select the specific information you want released by checking the relevant boxes under 'THE FOLLOWING INFORMATION FROM THE ABOVE NAMED PATIENT'S RECORD.'
6. If applicable, initial next to any sensitive information that you authorize for release.
7. Fill in the approximate dates of service and specify the purpose for requesting this information.
8. Finally, sign and date the form at the bottom. If signed by a representative, include their relationship to you.

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