Forms
Written Authorization
Requests for the release of medical records (protected health information) must be submitted in writing and must contain all the elements required by law.
The date(s) of service (date procedure or consultation was made)
The individual or entity to whom the information is to be released
The type of records to be released
The purpose of the request (why the information is needed)
Authorizations must also be dated and signed by the patient or the patient’s legally authorized representative. In the case of a minor, a parent or legal guardian must sign the authorization