AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION. Release of Information for the Palo Alto Medical Foundation 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name and date of birth in the designated fields at the top of the form.
3. Fill in the dates of service and your phone number to provide context for your request.
4. In the section labeled 'I authorize,' write the name and address of the entity you are authorizing to release your health information.
5. Next, specify who will receive this information by filling out their name and address in the recipient section.
6. Select which specific health information you wish to disclose by checking the appropriate boxes provided.
7. If applicable, indicate any restricted access information that should be included by initialing next to those options.
8. Clearly state the purpose for which your health information may be used in the designated area.
9. Set an expiration date for this authorization; if left blank, it will remain valid for one year from signing.
10. Finally, sign and date the form at the bottom, ensuring all required fields are completed before submission.

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