Lakeside Behavioral Health System 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s name in the designated field at the top of the form.
3. Next, specify the agency or individual to whom you are authorizing the release of information.
4. Indicate whether you permit faxing by circling 'Y' or 'N'.
5. Fill in the address and fax number of the recipient for accurate delivery.
6. Select the purpose for releasing medical information by checking one or more options provided.
7. Specify the time period of illness by entering relevant dates of service.
8. Check all applicable types of data you wish to be released, such as history and physical, discharge data, labs, and medications.
9. Sign and date the authorization at the bottom, ensuring all required fields are completed.

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