Hospital release form 2025

1. Click ‘Get Form’ to open the hospital release form in our editor.
2. Begin by entering the patient's name and date of birth in the designated fields at the top of the form.
3. In the authorization section, specify who is authorized to release information by filling in the name of the healthcare provider.
4. Next, provide the recipient's details, including their name, phone number, and address.
5. Select which protected health information you wish to disclose by checking the appropriate boxes for history/physical, discharge summary, etc.
6. If requesting an entire medical record for specific dates, fill in those dates accurately.
7. Initial next to any sensitive information categories that may be included in your disclosure.
8. Complete any additional sections regarding restrictions and purpose of disclosure as needed.
9. Finally, sign and date the form at the bottom. Ensure you print your name and indicate your relationship to the patient if applicable.

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