Patient First or Print Name of Provider to release my 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name. Fill in the Last, First, and Maiden or Other Name fields as applicable.
3. Provide your Date of Birth by selecting the month, day, and year from the dropdown menus.
4. Enter the last four digits of your Social Security Number in the designated field.
5. In the authorization section, print the name of your provider who will be releasing your medical records.
6. Fill in the provider's address, city, state, zip code, and phone number accurately.
7. Select which information you wish to be released by checking the appropriate boxes for Medical Record, X-rays, EKG, Itemized Statement, or Other.
8. Indicate the purpose of disclosure by checking one or more options provided.
9. Sign and date at the bottom of the form. If someone else is signing on your behalf, include their relationship and legal authority.

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