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ADVANCED PEDIATRICS Request for Release of Medical/Immunization Records DATE OF REQUEST Patient s Name Date of Birth Father s Name Account # Mother s Name Daytime Phone # Current Address Previous

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What is release of medical records?

Release of medical records is a process where a patient gives consent to a healthcare provider to release their medical information to another party, such as another healthcare provider or insurance company.

Who is required to file release of medical records?

The patient or their legal guardian is typically required to file a release of medical records in order to authorize the disclosure of their medical information.

How to fill out release of medical records?

To fill out a release of medical records, the patient or legal guardian must complete a form provided by the healthcare provider, specifying the information to be released and to whom it should be released.

What is the purpose of release of medical records?

The purpose of release of medical records is to ensure that healthcare providers have access to a patient's complete medical history in order to provide appropriate care and treatment.

What information must be reported on release of medical records?

The release of medical records form typically requires the patient's name, date of birth, medical record number, the information to be released, the recipient of the information, and the purpose of the release.

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