Get Release Of Information - Elmhurst Clinic - Elmhurstclinic

Completing the RELEASE OF INFORMATION form for the Elmhurst Clinic is a straightforward process that allows users to authorize the release of their medical records. This guide will help you navigate the online form by providing clear steps and explanations to ensure your request is processed efficiently.

Follow the steps to accurately fill out the form.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Read the introduction section carefully, as it outlines the necessity of providing a written authorization signed by the patient or their legal representative.
3. Fill in the patient’s name, including the first name, middle initial, and last name, as indicated in section 1.
4. Provide the patient’s birth date in the specified format: month/day/year.
5. In section 3, choose the person or organization that you authorize to release your medical records by checking one of the options provided.
6. Select how the protected health information will be released by checking one option in section 3b, such as being picked up or mailed.
7. Complete section 3c by entering the name, address, city, state, and zip code of the person, facility, or agency that is authorized to receive the information.
8. Input the dates of service for which you are requesting records in section 3d.
9. In section 3e, identify the specific information you wish to have released by checking all applicable boxes.
10. State the reason for the release of information in section 3f by checking all appropriate boxes.
11. Make sure to read the disclaimers in sections 4 through 10 carefully and provide your signature, date, and any necessary information from legal representatives if applicable.
12. After completing the form, review it for accuracy. Then, save any changes you made, download, print, or share the form as necessary.

Start completing your RELEASE OF INFORMATION form online today for a faster processing experience.