Authorization for release of medical information - Intuitive Psychology 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient’s legal name and date of birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the patient's address, including city, state, and zip code. This helps in verifying the patient's identity and location.
4. Provide both home and daytime phone numbers for contact purposes. This ensures that the requestor can reach you if needed.
5. Indicate the dates of treatment and social security number (SS#) if required. This information may be necessary for processing your request.
6. Select the purpose of disclosure by checking one or more options provided, such as continuing medical care or attorney request.
7. Authorize Intuitive Psychology to release or obtain specific medical records by checking the relevant boxes, ensuring you include any sensitive information if applicable.
8. Complete the requestor/provider section with their details, including name, address, and contact information.
9. Sign and date the form at the bottom. If applicable, a guardian or authorized person should also sign with their relationship to the patient.

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