Atlantic health system authorization form 2025

1. Click ‘Get Form’ to open the Atlantic Health System Authorization Form in our platform.
2. Fill in today’s date, your name, date of birth, medical record number (if known), address, and daytime phone number in Section A.
3. Select the Atlantic Health System facility where you received treatment by checking the appropriate box.
4. Provide the recipient's name and address who will receive the records. If it's the same as your name, check the corresponding box.
5. Indicate the purpose for requesting your medical records by checking one of the options provided.
6. Choose your preferred delivery method for receiving your records: paper copy, electronic media, MyChart, etc., and fill in any necessary details.
7. In Section B, if applicable, provide information about any other facility from which records are being requested.
8. In Section C, specify what information you want released by checking the relevant boxes or writing in specific requests.
9. Sign and date Section D to authorize the release of your information. If signed by a representative, indicate their relationship to you.

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