Authorization for Use/Disclosure of Protected Health Information 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name and Date of Birth in the designated fields. This information is crucial for identifying the individual whose health information is being authorized for release.
3. Fill in the Phone Number and Address of the patient. Ensure accuracy as this may be used for follow-up communications.
4. Specify the Person(s) or Organization(s) authorized to receive the information. Clearly write their names and addresses to avoid any confusion.
5. Indicate your preferred method of contact by filling in the Email, Phone Number, and Fax Number fields.
6. Select what specific health information you are authorizing for disclosure. You can choose between Complete Medical Record, Partial Medical Record, or Other Specific Information. Be sure to specify dates where applicable.
7. Initial next to any types of information you do not authorize for release, such as Substance Abuse, Mental Health Info, or HIV Info.
8. Provide a description of how the information will be used and note that this authorization will expire one year from the date signed unless specified otherwise.
9. Sign and date the form at the bottom. If you are signing on behalf of someone else, include your relationship to the patient.

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