The Kettering Health Network (Hospital) authorization form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth, Phone Number, and Social Security Number in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Specify the Date of Treatment and select the Specific Facility needed by checking the appropriate box from options like Kettering, Grandview, or others listed.
4. Indicate the purpose of your request by checking one or more boxes such as Continuity of care or Legal matter. This helps clarify why you need access to the health information.
5. Authorize Kettering Health Network to disclose health information by selecting the types of information required. Check all relevant boxes including Face Sheet, Consultation, and others as applicable.
6. Provide details about who will receive this information by filling in their Name, Address, and Phone number in the specified fields.
7. Finally, sign and date the form at the bottom. If signed by a legal representative, include their relationship to the patient.

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