Altheimer, MD 2026

1. Click ‘Get Form’ to open the Altheimer, MD document in the editor.
2. Begin by entering your Patient Name and Date of Birth in the designated fields. Ensure accuracy for proper identification.
3. Fill in your Street Address, City/State/Zip, and Daytime Phone number. This information is crucial for communication regarding your medical records.
4. In the 'I Authorize' section, provide the Name of Doctor, Specialty, Phone, and Fax numbers of the doctor releasing your records.
5. Next, specify the recipient's details by filling out their Name of Doctor, Specialty, Phone, and Fax numbers.
6. Choose whether to send all records or specific ones by checking the appropriate boxes and providing any necessary date ranges or specifics.
7. Indicate the purpose for which you are requesting these records by selecting from the options provided.
8. Review the authorization statement carefully before signing. Ensure you understand what information is being released.
9. Finally, sign and date the form. If applicable, include your relationship to the patient if you are not signing as them.

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