Release of information 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, provide your Date of Birth, print your name, and fill in your address and contact details. This section confirms the revocation of permission for the Health Plan to disclose your Protected Health Information (PHI).
3. Complete Section B by entering the Personal Representative's name, Date of Birth, address, relationship to you, and their telephone number. This identifies who previously had access to your PHI.
4. In Section C, specify the effective date of revocation using the mm/dd/yyyy format. This indicates when your previous authorization is no longer valid.
5. Finally, sign and date Section D to authorize this revocation. If applicable, a Personal Representative can also sign here.

Start using our platform today for free to easily manage your release of information forms!