AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION - chsbuffalo: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the Patient Address and Telephone number. If applicable, include a Cell Phone number for additional contact options.
Specify the Date(s) of Treatment and Type(s) of Treatment received. This helps clarify what records you are requesting.
Indicate how you would like to receive your records by checking either 'Documents will be picked up' or 'Please mail the information to me at the address below.'
Select the Information Requested by checking all relevant boxes, such as Entire Record, Discharge Summary, etc.
Complete the purpose of authorization and validity period. This section outlines why you need access to your health information.
Sign and date the form at the bottom. If a Personal Representative is signing, ensure their details are filled out correctly.

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