Get Authorization For The Release Of Information - California State ... - Csulb

Filling out the Authorization For The Release Of Information is a straightforward process that allows you to grant permission to share your medical records. This guide will provide clear, step-by-step instructions to ensure you complete the form correctly and efficiently.

Follow the steps to complete the form online.

1. Press the 'Get Form' button to acquire the form and open it in the designated editor.
2. Begin by entering your personal details. Fill in your full name, campus ID number, address, city, state, zip code, current telephone number, and date of birth in the appropriate fields.
3. Specify the information you wish to release. Check the box for 'Complete Medical Record' or 'Other,' and provide details if you choose the latter.
4. State the purpose for the release. Indicate whether it is for 'Personal Records' or 'Other' and describe accordingly.
5. Read and understand the liability release clause. By proceeding, you acknowledge that CSULB Student Health Service is released from any liability regarding this authorization.
6. Authorize the release of your medical information. Indicate whom the information should be released to by checking the appropriate box (Self or Name) and filling in the required details.
7. Choose how you wish to receive the records by specifying if they will be picked up, mailed, or faxed.
8. Provide your signature and date to confirm your authorization. If you are under 18, a parent or guardian signature is also required.
9. Finally, save your changes, download the form, print it for your records, or share it as needed.

Complete your Authorization For The Release Of Information online today!