AUTHORIZATION FOR RELEASE OF INFORMATION (for Use and - ukhealthcare uky 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Social Security Number, Date of Birth, and Phone Number in the designated fields. This information is crucial for identification purposes.
3. Fill in your Patient Name and Address details, including City, State, and Zip Code. Ensure accuracy to avoid any delays.
4. Select the Type of Release you require by checking the appropriate boxes. Options include TRACQuest, CD, or Paper formats.
5. Indicate where you want the information sent from and to by filling in the relevant sections. If sending to a different address, specify that clearly.
6. Specify the dates for which you would like records. You can provide specific dates or a general range.
7. Check all relevant records you wish to obtain from the list provided. Be sure to include any special protected records if applicable.
8. Complete the reason for needing records section by checking all that apply.
9. Sign and date the form at the bottom. If applicable, ensure a Legal Representative signs as well.

Start using our platform today for free to streamline your document editing and signing process!