Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, Ca 95128, Telephone (408) 885- 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name in the designated field at the top of the form.
3. Fill in your Date of Birth and ID or Medical Record number to ensure accurate identification.
4. Provide your Address and Telephone number for contact purposes.
5. In the AUTHORIZATION section, specify who you are granting permission to use and release your health information.
6. Complete the RECIPIENT NAME and their Address and Phone details for where the information will be sent.
7. Indicate the PURPOSE for which your health information is being disclosed.
8. Select the INFORMATION TO BE RELEASED by checking appropriate boxes related to your medical records.
9. Choose your DELIVERY PREFERENCE and DELIVERY FORMAT based on how you want to receive your information.
10. Sign and date at the bottom of the form to finalize your authorization.

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