Pomona Valley Hospital Medical Center - Professional Legal ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient's Name, Date of Birth, and Social Security Number in the designated fields. Ensure accuracy as this information is crucial for identification.
3. In the 'Release Records To' section, provide the name or organization that will receive the health records. Include their phone number, address, city, state, and zip code.
4. Specify the purpose(s) of disclosure in the provided field. This helps clarify why the information is being shared.
5. Select which types of information you wish to release by checking the appropriate boxes such as Medical Records, Lab/Pathology Slides, etc. If applicable, describe any other specific information needed.
6. Initial where indicated to acknowledge understanding of sensitive information that may be included in your health records.
7. Sign and date at the bottom of the form. If you are a legal representative, indicate your relationship to the patient.

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