Patient Information Release Form - Henry Ford Health System 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your Patient Full Name, Date of Birth, and Last 4 Digits of SS#. Ensure all information is accurate to avoid processing delays.
3. Complete the Address section with your Street, City, State, and Zip code. This helps in identifying your location for any correspondence.
4. In the authorization section, clearly state the name or title of the person or organization you are authorizing to disclose your medical information. Fill in their address as well.
5. Select the purpose for disclosure from options like 'At the request of the patient' or 'Insurance'. This clarifies why you need this information shared.
6. Indicate specific information to be disclosed related to your request. You can choose from options such as 'ER Memo', 'X-Ray/Lab', etc., and specify dates if necessary.
7. Review all filled sections for completeness. Remember that incomplete forms will be returned unprocessed. Finally, sign and date the form before submission.

Start using our platform today to easily fill out and manage your Patient Information Release Form!