AUTHORIZATION FOR RELEASE OF INFORMATION - Ohio 2025

1. Click ‘Get Form’ to open the AUTHORIZATION FOR RELEASE OF INFORMATION - Ohio in the editor.
2. Begin by filling in your full name and date of birth at the top of the form. This information is essential for identifying you as the individual authorizing the release.
3. In the section labeled 'Specific Identification of Person or Entity Authorized to Receive Information', enter the name of the person or organization that will receive your medical information.
4. Indicate the dates of treatment for which you are authorizing information release. This helps narrow down the records being shared.
5. Select which specific types of information you wish to be released by checking the appropriate boxes, such as 'Progress Notes' or 'Lab Results'.
6. If applicable, specify any records from other providers that should be included by writing their names in the designated area.
7. Complete any additional exceptions or exclusions regarding what information should not be released, if necessary.
8. Finally, sign and date the form at the bottom. If someone is signing on your behalf, ensure their authority is documented as well.

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