Follow the steps to fill out the form correctly.

1. Press the ‘Get Form’ button to retrieve the form and open it in the editor.
2. Begin filling out the patient’s information, including the patient's name, date of birth, last four digits of the Social Security number, and medical record number. Ensure accuracy in entering these details.
3. If applicable, provide the representative's name and their relationship to the patient. Include the representative's address and legal authority if required.
4. In the 'Authorization' section, read the statement carefully and indicate your consent by signing the form. This authorizes the custodians to disclose the protected health information (PHI).
5. List the recipient(s) of the medical records under 'Release to' and 'Obtain from.' Ensure that the names and addresses are complete and accurate.
6. State the purpose for requesting the records in the designated field. Be clear and concise.
7. Indicate the specifics of the PHI you wish to disclose by marking the appropriate options under section A, B, or C. Add any necessary details for clarity.
8. Sign and date the authorization section at the bottom of the form. Include the printed name of the patient or personal representative, and specify the relationship if applicable.
9. Review all the information provided for accuracy. Make any necessary corrections and ensure all required fields are completed.
10. Finally, save your changes, then download, print, or share the form as needed based on your requirements.

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