Health Information Management Phone (760) 323 6289; Fax (760) 323 6201-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name and MRN in the designated fields at the top of the form.
3. Fill in the Date of Birth by selecting the month, day, and year from the dropdown menus.
4. In the 'I AUTHORIZE' section, specify both the name of the person or facility releasing information and the recipient's details.
5. Indicate which specific health information you wish to release by checking the appropriate boxes.
6. Specify any date or time periods for the requested information in the provided space.
7. State your purpose for this release by checking one of the options provided.
8. Initial where indicated to confirm understanding of your rights regarding this authorization.
9. Finally, sign and date at the bottom of the form, ensuring all required fields are completed before submission.

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