Authorization for release of medical information - UnityPoint Health 2026

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

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