Consent for Release of Confidential Health Information - York Hospital 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the 'Patient Name' field. This identifies you as the individual authorizing the release.
3. Select the appropriate box to indicate who is authorized to disclose your health information, such as York Hospital or another healthcare facility.
4. Fill in your medical record number and address details, including city, state, zip code, and phone number.
5. Specify the date range for which you authorize the release of medical records.
6. Indicate who will receive this information by filling in their name and address.
7. Check all relevant boxes under 'Specific Description of the Information to be Disclosed' that apply to your situation.
8. Provide a reason for the disclosure by checking one or more options listed under 'Specific Description of the Purposes of the Disclosure.'
9. Initial next to any sensitive information categories that apply, such as AIDS/HIV or mental health records.
10. Sign and date the form at the bottom. If applicable, have a legal representative sign as well.

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