Download - Optim Orthopedics - Optim Healthcare 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the 'Patient Full Name' field, followed by any other names you may have. Fill in your address, date of birth, city, state, zip code, and phone number.
3. In the 'Release Information To' section, provide the name or facility that will receive your health information. Include an attention line if necessary, along with their address and phone number.
4. Select the purpose of your request by checking the appropriate box (e.g., Personal, Treatment, Legal). Specify how you would like records to be forwarded: via Mail, Fax, or Email.
5. Indicate what information you want released by checking one of the options provided. If you have specific requests, write them in the space provided.
6. Finally, read and acknowledge the authorization statement at the bottom. Sign and date the form to complete your request.

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