Richmond health information management service center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A. Fill in the Patient Name, Date of Birth, and Patient’s Phone. The Last 4 digits of SSN is optional but can be included for identification.
3. Enter the Provider’s Name and Recipient’s Name along with their respective addresses and phone numbers. Ensure all information is accurate for proper processing.
4. Specify the Request Delivery method. Choose between Paper Copy, Electronic Media, Encrypted Email, or Unencrypted Email based on your preference.
5. Indicate the expiration date or event for this authorization. This will help clarify how long the authorization remains valid.
6. In the Description of Information section, check all relevant boxes that pertain to your request. Be mindful of any fees associated with document requests.
7. Complete Section C by signing and dating the form. If someone else is signing on behalf of the patient, include their relationship to the patient.

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