Get Authorization For Access/release Of Information Form

Completing the Authorization For Access/Release Of Information Form online is an essential step in granting access to your medical records. This guide will walk you through each section of the form, ensuring that you provide all necessary information accurately and completely.

Follow the steps to successfully complete the form online.

1. Click 'Get Form' button to obtain the form and open it in your preferred online editor.
2. Enter your full legal name as the patient, referred to as 'Requestor'. Make sure to print your name legibly.
3. Input your date of birth in the required field to establish your identity.
4. If applicable, include your maiden name or any prior names to ensure accurate records.
5. Fill in your complete address, including street, city, state, and zip code.
6. Provide your daytime phone number for contact purposes.
7. Specify the name of the physician or provider from whom you are requesting records, as indicated in the designated field.
8. Check the appropriate office location where you mainly receive medical care.
9. Enter the name and address of the person or entity you are authorizing to receive the records ('Receiver').
10. Provide their telephone number and fax number if applicable.
11. Select the reason for requesting the records by checking the corresponding box.
12. Specify the dates of service for which records are being requested in the fields provided.
13. Indicate the specific types of information you wish to be disclosed by checking the appropriate boxes.
14. If there are any types of information you wish to exclude from disclosure, specify them in the designated area.
15. Read and initial each statement provided, demonstrating your understanding of the authorization and your rights.
16. Sign the form, print your name if you are not the patient, and indicate your relationship to the patient.
17. Include the date of signing the form.
18. If needed, arrange for a witness to sign and date the form.
19. After completing the form, you can save any changes, then download, print, or share the form as necessary.

Take the next step by completing your Authorization For Access/Release Of Information Form online today.