Henry ford release of information 2026

1. Click ‘Get Form’ to open the henry ford release of information in the editor.
2. Begin by filling in your Patient Full Name, Maiden Name, Date of Birth, Last 4 Digits of SS#, Sex, and Telephone number in the designated fields.
3. Provide your complete address including Street, City, State, and Zip Code.
4. In the authorization section, clearly state who is authorized to disclose your medical records. This includes filling in the name and title of the person or organization.
5. Select any specific medical records you wish to include by checking the appropriate boxes for services such as Alcohol and Substance/Drug Abuse diagnosis and treatment or Psychotherapy Notes.
6. Indicate the specific information to be disclosed by checking relevant service types and providing dates of service where applicable.
7. Sign and date the form at the bottom. Ensure that if you are signing on behalf of someone else, you indicate your relationship.

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