Phone: 301-545-1417 Fax: 301-545-1416-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's full name in the designated field at the top of the form.
3. Fill in the street address, city, state, and zip code for accurate identification.
4. Provide the date of birth in the specified format (Mo/Day/Yr) and include the social security number.
5. Enter a daytime phone number where you can be reached.
6. In the authorization section, clearly print your name and specify the time period for which records are requested.
7. Select which types of medical records you wish to release by checking the appropriate boxes.
8. Indicate whether you authorize the release of HIPAA protected information by initialing one of the options provided.
9. Complete the recipient's information, ensuring that all fields are filled accurately for proper delivery.
10. 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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