Fill out the information below and mail to: Mary ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your personal details. Enter the patient name, social security number, date of birth, and daytime phone number in the designated fields.
3. Provide your address in the specified section to ensure accurate delivery of information.
4. Indicate whether you authorize the release of information from a specific facility by checking the appropriate box and providing the facility's name.
5. Select your preferred method for receiving documentation by checking either 'Paper', 'CD', or 'Online Record eDelivery' and entering your email address if applicable.
6. Specify the dates of service for which you are requesting records by filling in both start and end dates.
7. Check all types of information you wish to be released from the list provided, ensuring you include any special requests as needed.
8. Complete the recipient's details, including their name, street address, city, state, and zip code.
9. State the purpose for which this information is being disclosed in the designated area.
10. Finally, sign and date the authorization section at the bottom of the form. Ensure that you understand your rights regarding this authorization before submitting.

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