Patient Instructions for Form 731 Limited Patient 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name at the top of the form. Ensure that you print your name clearly.
3. Next, provide your Social Security Number (last four digits) and Date of Birth for identity verification. This information will be kept confidential.
4. Identify the Entity Requested to Release Information. This is the person or organization authorized to disclose your health information.
5. In the section Who will be authorized to receive information, enter the name, address, and phone number of the individual or entity designated to receive your PHI.
6. Specify the Description of Information to be disclosed. You can choose to disclose your entire patient record or select specific items such as lab results or office notes.
7. Indicate the Purpose of Disclosure by selecting 'Patient Request' or specifying another reason for sharing your information.
8. Review and complete the Expiration or Termination section, noting that this authorization expires at year-end unless specified otherwise.
9. Sign and date the form at the bottom. Remember, you must sign each year for this authorization to remain valid.

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