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20700 Bond Rd NE, Building B, Suite 104 Polls, WA 98370 Tel: 360.930.6314 Fax: 360.626.1292 Email: PSR psrheum.com Web: www.psrheum.com AUTHORIZATION TO RELEASE MEDICAL PROVIDER RECORDS TO PUGET SOUND
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How to fill out authorization to release primary
How to Fill Out Authorization to Release Primary:
01
Start by writing your full name at the top of the form.
02
Provide your contact information, including your address, phone number, and email.
03
Indicate the purpose of the authorization and specify the primary information you want to release.
04
State the duration of the authorization, whether it is a one-time release or ongoing.
05
If applicable, include any limitations or restrictions on the release of information.
06
Read the authorization form carefully and make sure you understand its contents.
07
Date and sign the authorization form at the bottom.
08
Make copies of the completed form for your records.
09
Submit the authorization form to the appropriate party or organization.
Who Needs Authorization to Release Primary:
01
Individuals who require the release of their primary information for a specific purpose.
02
Patients or clients who want their medical or personal records to be shared with another healthcare provider or organization.
03
Students who need to allow their educational institutions to release their academic information.
04
Job applicants who authorize their previous employers to disclose their employment history to potential employers.
05
Any person who wishes to grant permission for the release of their primary information to another party or organization.
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