Form online 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Patient Information section. Enter your name, date of birth, street address, phone number, city/state/zip code, email address, and any alternate contact numbers.
3. In the Request Authorization section, select the Piedmont provider from which you wish to disclose records. Provide their phone and fax numbers as needed.
4. Specify how you would like the records disclosed in the Disclosure section by choosing between Secure E-mail Portal, Mail, or MyChart.
5. Complete the Description of Information for Release section by indicating the type of medical records you are requesting and listing your date of service.
6. Finally, sign and date the authorization at the bottom of the form. If applicable, provide details about your relationship to the patient if you are a legal representative.

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