Authorization for Disclosure of Health Information 2025

1. Click ‘Get Form’ to open the Authorization for Disclosure of Health Information in our editor.
2. Begin by filling out the Patient Information section. Enter your name, address, city, phone number, date of birth, state, zip code, and any previous names if applicable.
3. In the Authorizes section, provide the name and address of the health care provider or plan that you are authorizing to disclose your information.
4. Specify who will receive the disclosed information in the To Disclose To section. You can choose 'Self' or designate another person.
5. Select your preferred delivery options for receiving your records: view on site, mail to your address, pick up in person (photo ID required), or send to another provider.
6. Indicate the dates of information to be disclosed. If left blank, only information from the past two years will be shared.
7. Check all relevant boxes under Information to be Disclosed to specify what type of health information you want shared.
8. Fill in the expiration date for this authorization. If left blank, it will expire one year from the date signed.
9. Complete the Purpose section by checking all applicable reasons for disclosure.
10. Review your rights regarding this authorization before signing at the bottom. Ensure you understand your rights and any potential fees involved.

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