Authorization for the Release of bMedicalb Record Information - childrenshospital 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Demographics section. Enter the patient's last name, first name, middle initial, home address, city, state, zip code, and contact numbers.
3. In the authorization section, specify who is authorized to receive the medical records by providing their name or facility and contact details.
4. Select the purpose of release by checking the appropriate box (e.g., Medical Care, School or Camp).
5. Choose the format for release (CD, Paper, Fax) and specify any additional information needed in the 'Information Requested' section.
6. On page 2, review and initial all elements you agree to have released. Ensure you understand what information may be disclosed.
7. Finally, sign and date at the bottom of page 2. If applicable, a parent or guardian must also sign for patients under 18.

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