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, along with their phone number and address. This ensures proper delivery of the requested information.
4. Specify the Purpose(s) of Disclosure. Clearly outline why you are requesting this information, including any limitations on its use.
5. Select which types of information you wish to be released by checking the appropriate boxes, such as Medical Records or Lab/Pathology Slides.
6. If applicable, specify Dates of Treatment to narrow down the records being requested.
7. Initial where indicated to acknowledge understanding of sensitive information that may be included in your health record.
8. 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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