Callen lorde hipaa release form 2026

1. Click ‘Get Form’ to open the Callen-Lorde HIPAA Release Form in the editor.
2. Begin by filling out Section 1: Patient Information. Enter your last name, first name, today's date, address, apartment number (if applicable), city, state, date of birth, phone number, and zip code.
3. Move to Section 2: Release Information To. Authorize Callen-Lorde Community Health Center to share your health information by providing the organization’s name, address, city, state, zip code, phone number, and fax number.
4. In Section 3: Information to be Disclosed, indicate how you want the information released (fax, mail, or pick-up) and check 'Yes' or 'No' for each type of medical and dental record you wish to disclose.
5. Proceed to Section 4: Sensitive Information. Sign next to any categories of sensitive information you authorize for release.
6. Complete Section 5: Release Reason & Time Frame by specifying the reason for the release and any expiration date if different from 12 months.
7. Finally, sign at the bottom of the form as acknowledgment of your understanding and authorization.

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