AUTHORIZATION TO RELEASE OR REQUEST PROTECTED HEALTH INFORMATION 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's full name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the contact number and mailing address of the patient. This helps maintain communication regarding the request.
4. Indicate whether you are authorizing the release of information or requesting it from another entity by checking the appropriate box.
5. List the authorized entity's name, address, and contact details where the information will be sent or requested from.
6. Specify any limitations on the release of information, such as treatment dates or specific records needed, by checking relevant boxes.
7. Select the purpose of this authorization from the provided options, ensuring it aligns with your needs.
8. Sign and date the form at the bottom. If applicable, indicate your relation to the patient.

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