Authorization for disclosure of patient medical ... - Beaumont 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated field at the top of the form.
3. Next, specify the name of the person or organization releasing information, which is William Beaumont Hospital or another entity if applicable.
4. Fill in the address of the hospital or organization from which you are requesting records.
5. Provide your phone number and birthdate in the respective fields to ensure accurate identification.
6. Indicate who will receive the disclosed information by filling out their name, phone number, address, and fax number if necessary.
7. Select specific types of information to be disclosed by checking appropriate boxes such as discharge summary, labs, or operative reports.
8. State the purpose for this disclosure by selecting from options like continuation of treatment or billing information.
9. Choose how you would like the information delivered: mailed, picked up, or faxed. If someone else will pick it up, include a letter of authorization.
10. Finally, sign and date the form at the bottom. If signing on behalf of a minor or authorized representative, include necessary paperwork.

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