Release form from jfk hospital 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A, entering the Patient Name and Birth Date. Ensure accuracy as this information is crucial for identification.
3. Fill in the Provider’s Name and Recipient’s Name. If applicable, include the last four digits of the SSN for additional verification.
4. Complete the address fields, including Address 1, Address 2 (if necessary), City, State, and Zip Code.
5. Select your preferred Request Delivery method: Paper Copy or Electronic Media. If you choose electronic delivery, provide a legible Email Address.
6. Specify when this authorization will expire by filling in either a Date or an Event but not both.
7. Indicate the Purpose of Disclosure and describe the information to be used or disclosed. Check any relevant items from the list provided.
8. Acknowledge consent regarding sensitive information by initialing where indicated.
9. In Section C, sign and date the form. If applicable, print your name and relationship to the patient.

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