6507259821 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section A with the patient's name, date of birth, phone number, and medical record number. Ensure all information is printed clearly.
3. In Section B, specify the health information you wish to release. Check the appropriate boxes and initial next to them for authorization. If you want specific dates of service or additional details, provide that information as required.
4. Complete Section C by indicating the recipient's name and address who will receive the health information.
5. In Section D, state the reason for releasing your health information or check if you prefer not to provide a reason.
6. Choose how you would like the information sent in Section E—by mail, pick-up, inspection, or fax in emergencies.
7. Fill out Section F with an expiration date for this authorization; if left blank, it will expire one year from signing.
8. Review Sections G and H for privacy rights and cautions before signing. Finally, sign and date in Section I to authorize the release.

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