Authorization to release the protected health information of: - intermountainhealthcare 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name, MRN, current address, phone number, and date of birth in the designated fields.
3. Specify the recipient's details by filling in their name, address, and preferred delivery method (In Person, Mail, Phone, Fax, Secure Email).
4. Indicate the facility or provider from which you are requesting information by entering their name and contact number.
5. Select the purpose of disclosure and specify the dates of service requested.
6. Choose which types of patient health information you wish to release by checking the appropriate boxes for each category.
7. Review the authorization duration options and select how long this authorization will remain effective.
8. Finally, sign and date the form. If applicable, include your relationship if signed by a personal representative.

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