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Authorization for release of medical information - UnityPoint Health 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in your name in the designated field, granting consent for the facility to release your medical records.
- Provide the facility name and address where your records are currently held, along with their contact number.
- Next, specify the recipient's name and their facility address/phone number where the records will be sent.
- Fill in your personal details including patient name, previous names (if any), date of birth, phone number, and address.
- Select whether you want information from a hospital or clinic by checking the appropriate box.
- Indicate what specific information is being requested by checking the relevant boxes for lab results, immunizations, x-rays, etc.
- Specify the date range for which you are requesting records.
- Choose the purpose of this authorization from options like insurance, legal matters, or personal use.
- Read through the acknowledgment section carefully before signing and dating the form. If applicable, have a witness sign as well.
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