Fill out the information below and mail to: Mary ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal details in the designated fields. Fill in your Patient Name, Social Security Number, Date of Birth, and Daytime Phone Number accurately.
3. Provide your Address in the specified section to ensure proper delivery of your records.
4. Select the preferred media for receiving documentation by checking one of the options: Paper, CD, or Online Record eDelivery. If you choose online delivery, enter your email address.
5. Indicate the Dates of Service for which you are requesting records by filling in both start and end dates.
6. Check all relevant boxes under 'Information to be Released' that apply to your request. Ensure you understand any limitations regarding sensitive records.
7. Complete the section for Person/Facility to Receive Information with accurate contact details.
8. State the purpose for which this information is being disclosed in the provided space.
9. Read through the Authorization to Release Information carefully before signing. Ensure you understand your rights regarding this authorization.
10. Finally, sign and date the form at the bottom before submitting it via mail or fax as indicated.

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