Release of Information - RiverBend Medical Group 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your Patient Information, including your full name, date of birth, address, and phone numbers. Ensure all details are accurate for a smooth process.
3. In the 'Release of Information' section, specify who you authorize RiverBend Medical Group to discuss your medical records with or where to mail copies. Include the name/facility and their contact information.
4. Indicate the purpose of your request by checking the appropriate box (e.g., Personal, Continuing Care). If applicable, provide specific dates of treatment and provider names in the 'Information to be Released' section.
5. For sensitive information, check 'Yes' or 'No' for each category listed and initial accordingly. This step is crucial for processing your request.
6. Finally, sign and date the form at the bottom. If applicable, have a parent or legally recognized representative sign as well.

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