Authorization to release medical records form 2025

1. Click ‘Get Form’ to open the authorization to release medical records form in the editor.
2. Begin by entering your personal information. Fill in your name, date of birth (DOB), and social security number (SSN) in the designated fields.
3. Provide your address, including city, state, and zip code, along with your phone number for contact purposes.
4. In the section labeled 'I hereby authorize UMHS to release my medical records from:', specify the name of the patient and select the entities from which you want records released.
5. Next, indicate who will receive this information by filling out their name, phone number, and address in the appropriate fields.
6. Select which specific information you wish to be released by checking the relevant boxes for items like progress notes or discharge summaries.
7. Specify the dates of treatment for which records are being requested by filling in the 'From' and 'To' fields.
8. Complete any additional sections regarding sensitive information releases as necessary by checking 'Yes' or 'No'.
9. Finally, sign and date the form at the bottom. If signed by a legal representative, include their authority description.

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