Get Authorization For Release Of Medical Records

This guide provides clear and supportive instructions on completing the Release and Authorization to Use Name in Book to be Published form online. By following these steps, you can ensure that your information is accurately submitted and that you fully understand the implications of the authorization.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the date of the release at the designated line labeled _____________. This should reflect the date you are completing the form.
3. Enter your name on the line marked ‘Name of Releasor’. This signifies the individual granting authorization for their name to be used.
4. Provide your city and state on the line labeled ‘city, state’. This helps identify your location as the Releasor.
5. Fill in the name of the Author on the line indicated as ‘Name of Releasee’. This is the individual who will be using your name.
6. Complete the Author’s city and state on the line marked ‘city, state’. This information is important for confirming the Author's location.
7. Write the title of the book in the space provided after ‘entitled or to be entitled’. Ensure that this title is accurate, as it represents the work in which your name will appear.
8. Carefully read the sections listed (I through IV) that describe your rights and responsibilities as the Releasor. It is critical to understand what you are consenting to regarding the use of your name.
9. Sign your name on the designated line at the bottom of the form next to ‘Releasor’. This indicates your agreement and consent to the terms laid out in the form.
10. Ensure that the Author signs their name on the line next to ‘Author’. This completes the authorization process.
11. After filling out all required fields, proceed to save any changes, download a copy, print the document, or share the completed form as necessary.

Complete your documents online efficiently and securely.