X'xxcom 2025

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3.9 out of 5

47 votes

The document is an authorization form from LeBauer Medical Center, PLLC, allowing the use and disclosure of a patient's protected health information, including sensitive data related to mental health and substance abuse. It outlines the patient's rights regarding the release of their medical records, specifies the purpose of disclosure, and includes instructions for revocation of the authorization. The patient must provide their signature and date to validate the request.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your Patient Name and Date of Birth in the designated fields. Ensure that the information is accurate as it will be used for identification purposes.
In the section labeled 'TO RELEASE INFORMATION TO:', fill in the name, address, phone number, and fax number of the individual or organization you wish to receive your health information.
Next, complete the 'TO OBTAIN INFORMATION FROM:' section with similar details for the source of your health records.
Specify the purpose of disclosure by selecting from options such as employment or insurance needs. This helps clarify why you are requesting this information.
Indicate the time period for which you authorize medical records to be released by filling in the 'From' and 'To' dates.
Select which specific types of information you want sent by checking all applicable boxes, including office visit notes and lab results.
Read and initial each statement regarding authorization expiration and revocation to confirm your understanding before signing at the bottom.

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Versions	Form popularity	Fillable & printable
2024	4.3 Satisfied (21 Votes)
2024	4.6 Satisfied (51 Votes)
2024	4.5 Satisfied (23 Votes)
2024	4.8 Satisfied (29 Votes)
2023	4.7 Satisfied (42 Votes)
2023	4.4 Satisfied (48 Votes)
2023	4 Satisfied (63 Votes)
2023	4.5 Satisfied (26 Votes)
2023	4.6 Satisfied (34 Votes)
2023	4.2 Satisfied (30 Votes)
2023	3.9 Satisfied (31 Votes)
2023	4.3 Satisfied (42 Votes)
2023	4.7 Satisfied (39 Votes)
2023	4.4 Satisfied (22 Votes)
2023	4.2 Satisfied (51 Votes)

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