Release of Protected Health Information Instructions
1. Complete the first section with current patient name, date of birth, phone number,
address and if possible, a social security number.
2. Purpose of Request: Why do you want this information copied or sent? (ie., personal copy continuation
of care by a physician, insurance claim, legal issues,etc.)
3. Person(s)/Facility Authorized to receive: If the copies are for personal reasons and you are picking them up –
state “self”. If “self” and the address is the
same as the top section, this can be left blank and indicate “same”.
If the records are being picked up by another person or mailed, please
provide the complete name and address of the person/agency/etc., you would
like us to give/send the copies.
8. Specify dates: Please be as specific as possible with the admit/discharge dates. The
approximate month and correct year will be acceptable.
7. Type of documents requested: Please mark all boxes that apply. An abstract version may be provided
which would include all diagnostic and dictated/typed physician reports.
6/7. Drug and Alcohol Abuse: Please fill out 6 and 7 according to the direction on the form.
8. Time Limit: This authorization will be good for one year after the authorization is
signed at the bottom of the form unless otherwise indicated.
9/10. Signature Line: Sign and date the form. All signatures will be verified.