Release Authorization - Pueblo Community Health Center 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Date of Birth (DOB), and Medical Record Number in the designated fields.
3. Fill in the Address, Telephone Number, and Email Address to ensure accurate contact information.
4. In the authorization section, specify whether you are authorizing release or receipt of medical records by circling the appropriate option.
5. Provide the name and phone number of the individual or organization receiving the information, along with their address.
6. Indicate what specific information is to be released by selecting from options like 'Entire Medical Record' or specifying other details.
7. Choose how you want the information released: Paper or Electronic.
8. List any restrictions on the information being disclosed if applicable.
9. State the purpose for which this disclosure is being made in the provided field.
10. Sign and date at the bottom of the form, ensuring all required fields are completed before submission.

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