Get Authorization For Release Of Medical Or Mental Health Information

This guide provides step-by-step instructions on how to accurately complete the Authorization For Release Of Medical Or Mental Health Information online. By following these instructions, you will ensure that your health information is released safely and in accordance with applicable laws.

Follow the steps to complete the authorization form online.

1. Click ‘Get Form’ button to obtain the Authorization For Release Of Medical Or Mental Health Information form and open it in your chosen online editor.
2. Fill in your full name in the 'Client Name' field, followed by your date of birth in the respective section. This identifies you as the individual whose information is being authorized for release.
3. Provide your current address and phone number in the specified fields to facilitate communication regarding your authorization.
4. Indicate your expected graduation year, if applicable, ensuring that the purpose of this authorization is clear.
5. Identify the person or facility that currently holds your medical or mental health information. Write their name in the section labeled 'I authorize:' to specify the source of the information.
6. Include the recipient's name and address, which indicates where the information will be sent. If there are multiple recipients, fill in additional fields as needed.
7. Select the type of disclosure you are authorizing by checking the appropriate boxes for verbal information, letter/summary, or any other specified type.
8. Circle the type of records you wish to authorize for release: medical records, mental health/counseling records, or both. This informs the recipient of the exact documentation needed.
9. Note any specific restrictions you want to apply regarding the information being disclosed in the provided space.
10. Clearly state the purpose of the disclosure in the designated section. Be as detailed as possible to ensure proper understanding.
11. Indicate the expiration date of your authorization. If left blank, it will expire 12 months after your signature, as per guidelines.
12. Sign the form in the 'Signature of Client' section and provide the date to finalize your authorization.
13. If you wish to revoke the authorization, complete the designated section with your request and signature.
14. After completing the form, save your changes. You may then download, print, or share the form as needed.

Take the next step in managing your health information by completing your documents online.