I hereby authorize: - Georgia Department of Community Health - dch georgia 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'Name of Recipient' and their address. Ensure accuracy for proper delivery.
3. Select your preferred method of receiving records: mail, fax, or pick-up. If choosing pick-up, note the available locations and times.
4. Indicate whether you are requesting your own records or those of a child. Fill in the necessary details such as name and date of birth.
5. Specify the type of records you need, including any specific time frames or formats (e.g., paper, CD).
6. Review the section on disclosure limitations. Initial next to any types of information you do not wish to release.
7. Complete the duration section by specifying how long this authorization remains effective.
8. Sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship.

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