AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION Patient Name: Date of Birth: Phone: Address: City: State: Zip: Above listed patient authorizes the following healthcare facility to make record disclosure: Facility Name: Facility 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 correct medical records.
3. Fill in the Phone, Address, City, State, and Zip code of the patient to ensure accurate communication.
4. In the section authorizing record disclosure, enter the Facility Name and Facility Phone number where records will be requested from.
5. Complete the Facility Address details including City, State, and Zip code for precise location identification.
6. Specify the Dates and Type of information to disclose. Check appropriate boxes for reasons such as 'Change of Insurance' or 'Continuation of care'.
7. Indicate who will receive this information by filling out the Release To section with their name and address.
8. Finally, sign and date the form at the bottom to validate your authorization.

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