Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In the first section, provide the name, telephone number, address, city, state, fax number, and zip code of the individual or agency authorized to disclose protected health information (PHI).
3. Next, enter the patient's details including their name, DOC number, address, housing unit, date of birth, city, telephone number, state, and zip code.
4. Fill in the recipient's information by providing the name, telephone number, address, city, state, fax number, and zip code of the individual or agency receiving the PHI.
5. Indicate the specific protected health information authorized for use or disclosure by checking the relevant boxes. You can authorize a two-way release for ongoing communication between the parties.
6. If applicable, specify the time period for the records by entering start and end dates. If no dates are entered, only records from the last 12 months will be disclosed.
7. Check the appropriate purpose for the disclosure of protected health information, such as ongoing healthcare or legal representation.
8. Review the patient rights section, which outlines the rights to refusal, withdrawal, and inspection of PHI.
9. Finally, sign and date the form where indicated, ensuring that the authorization expiration is appropriately filled out.
10. Once completed, you can save changes, download, print, or share the form as needed.

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