Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering your full name in the designated field labeled 'I, (patient name)'. This identifies you as the individual granting authorization.
3. In the section labeled 'Hereby authorize:', enter the name of the hospital or facility that you wish to obtain records from.
4. Specify to whom you are disclosing your medical records by filling out 'To: (name and address of individual/facility)'. Make sure to include the complete address.
5. Select the purpose for the disclosure by checking the appropriate box, whether it is for continued care, personal use, legal reasons, or other specified purposes.
6. Indicate the dates of service for which you are requesting records. You may also specify the type of information to be disclosed by selecting the relevant checkboxes such as lab reports, diagnostic imaging reports, billing records, etc.
7. If applicable, consent to the release of specific protected health information by checking the relevant options regarding psychiatric treatment, HIV/AIDS, or drug and alcohol information.
8. Review the validity period of your authorization, noting that it is valid for 90 days or until you specify an alternative date. Ensure you provide your birthdate and telephone number in the designated fields.
9. Sign and date the form where indicated. If you are a guardian or legal representative, make sure to indicate your relationship.
10. If necessary, have a witness sign the form as required by the facility’s policy.
11. Finally, save your changes, download a copy of the completed form, print it for your records, or share it as needed.

Complete your Providence Medical Records Release Form online today for a hassle-free experience.