We encourage communication between healthcare providers, but this form is optional. It is up to you if you want information shared or received between us and your other health care providers. This authorization allows us to send and/or receive information from your healthcare providers. These forms are valid for one year.
1. Fill out the top section of the form with your information.
2. If you want your healthcare provider to release information to us, please check the box that says “to release the following information to
3. If you want us to release information to your healthcare provider, please check the box that says “request the following information from
Note: You can check BOTH the release and request boxes. This is recommended unless you don’t want information shared.
4. On the next line, write the healthcare providers names and locations. If you have the exact address and fax number, please enter that information. If you do not have this information, try to at least include the city and name of the practice. (i.e. Dr. Robert Ellis; OHA Springfield,
5. Under information to be shared, check “Entire Medical Record” unless you want to specify specific dates of records or specific records under "Other"
6. Sign the bottom of the form if you are the patient. If someone has legal authority for you (i.e. a parent for a minor), then have the legal authority sign and write a description below (i.e. parent
7. Make sure you date the form with the correct date and year or the form will be invalid.
8. If you want the form to be valid for longer than a year, you can specify a specific expiration date.