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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's full name in the designated field at the top of the form.
- Fill in the street address, city, state, and zip code for accurate identification.
- Provide the date of birth in the specified format (Mo/Day/Yr) and include the social security number.
- Enter a daytime phone number where you can be reached.
- In the authorization section, clearly print your name and specify the time period for which records are requested.
- Select which types of medical records you wish to release by checking the appropriate boxes.
- Indicate whether you authorize the release of HIPAA protected information by initialing one of the options provided.
- Complete the recipient's information, ensuring that all fields are filled accurately for proper delivery.
- Sign and date at the bottom of the form to validate your request. Remember to review any associated fees before submission.
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