Authorization for release of medical information - UnityPoint Health 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your name and the facility name that will be releasing your records. Ensure you provide the correct address and phone number for accurate processing.
3. Next, specify the recipient's name and their contact details. This is crucial for ensuring your medical information reaches the right person or facility.
4. Complete the patient information section, including your date of birth and address. This helps verify your identity.
5. Indicate which type of information you are requesting by checking the appropriate boxes, such as hospital records or lab results.
6. Select the dates for which you want records released. This can help narrow down the specific information needed.
7. Choose the purpose of this authorization from the provided options, ensuring clarity on why you need this information.
8. Finally, sign and date the form at the bottom. If applicable, include a witness signature to validate your request.

Start using our platform today to easily complete your Authorization for release of medical information!