Authorization for Release Request of Protected Health 2025

1. Click ‘Get Form’ to open the Authorization for Release Request of Protected Health in our editor.
2. Begin by entering your MRN and Patient Name at the top of the form. This information is essential for identifying your records.
3. In the 'Authorization for Release of PHI' section, specify the name of the person or facility authorized to release your protected health information (PHI).
4. Next, fill in the details of the recipient facility, including their address and contact information. Ensure accuracy to avoid delays.
5. Indicate whether you would like a paper copy or an electronic copy of your records by checking the appropriate box.
6. Select the healthcare facility from which you are requesting PHI. You can choose from options provided or specify another clinic.
7. Check all types of records you wish to be released, such as medical consultations, lab reports, or psychological test results.
8. Specify any date or time period relevant to your request in the designated field.
9. Indicate the purpose of this release by checking one or more boxes provided on the form.
10. Finally, sign and date the form at the bottom. If someone else is signing on your behalf, include their relationship to you.

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