Health patient authorization form 2025

1. Click ‘Get Form’ to open the health patient authorization form in the editor.
2. Begin by entering your personal information, including your name, date of birth, last four digits of your Social Security number, address, and telephone number.
3. In the 'Release by' section, specify the facility that will disclose your protected health information. Fill in the facility's name and address.
4. Next, complete the 'Release to' section with the organization or individual who will receive your information. Include their name and address.
5. Indicate the treatment dates and select the type of disclosure authorized. You can choose from options like further medical care or personal use.
6. Specify how you would like to receive your records—by mail or fax—and provide any necessary details for delivery.
7. Review the authorization statement carefully before signing. Ensure all information is accurate and complete.

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