1. Print your full name, date of birth, address, social security number, and phone numbers.
2. Clearly state where you want your information to be obtained from and sent to. Make sure to provide a complete address and facility name for locations outside Clark County.
3. Identify what information you want disclosed. Note that unless otherwise specified, we release only the most recent two years of information.
4. Identify what if any information you want to be excluded.
5. Check the appropriate reason for disclosure box.
6. Complete the authorization end date section if you want it to expire on a specific date or after a specific event occurs. Otherwise all releases expire after 90 days.
7. Be sure to sign and date the release. If the patient is under the age of 18, this form must be signed by the patient’s parent or legal guardian.