Crestwood Medical Center: Home 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient's Name, Date of Birth, and Medical Record Number in the designated fields. Ensure all information is accurate to avoid any issues with authorization.
3. Fill in the Address, City, State, Zip, Telephone Number, and Email Address. This information is crucial for communication regarding your health information.
4. In the section authorizing the release of health information, specify the Facility Authorized to Release your Health Information and the Agency or Individual(s) Authorized to Receive it. Be thorough to ensure proper handling of your data.
5. Select which Health Information may be used or disclosed by checking the appropriate boxes. You can also specify any additional information if needed.
6. Indicate the periods of healthcare for which you are authorizing disclosure by filling in the From and To dates along with Account Numbers if applicable.
7. Choose the purpose(s) for which your health information will be used or disclosed by checking relevant options.
8. Finally, sign and date at the bottom of the form. If applicable, include your relationship to the patient and any necessary witness signatures.

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