Des Moines University Clinic Authorization for Release of Medical Information 2010 free printable template
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Des Moines University Clinic Health Information Management Dept. 3200 Grand Ave., Des Moines, IA 50312 Phone (515) 271-7836 Fax (515) 271-1726 AUTHORIZATION TO RELEASE MEDICAL INFORMATION The Medical
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How to fill out Des Moines University Clinic Authorization for Release
How to fill out Des Moines University Clinic Authorization for Release of Medical
01
Obtain the 'Authorization for Release of Medical Information' form from Des Moines University Clinic.
02
Fill out your personal information in the designated sections, including your full name, date of birth, and contact information.
03
Indicate the specific medical records you are requesting to be released by checking the appropriate boxes or writing in details.
04
Specify the recipient of the medical information, providing their name and contact details.
05
Sign and date the authorization form to validate your request.
06
If applicable, provide any additional documentation required for processing your request.
07
Submit the completed form to Des Moines University Clinic via mail, fax, or in person.
Who needs Des Moines University Clinic Authorization for Release of Medical?
01
Patients who want to access their medical records.
02
Individuals who need to share their medical history with a new healthcare provider.
03
Legal representatives or family members of a patient who require access to medical records following consent.
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What is Des Moines University Clinic Authorization for Release of Medical?
Des Moines University Clinic Authorization for Release of Medical is a legal document that allows patients to give permission for their medical records to be disclosed to specified parties.
Who is required to file Des Moines University Clinic Authorization for Release of Medical?
Patients who wish to share their medical information with other healthcare providers, family members, or organizations must file this authorization.
How to fill out Des Moines University Clinic Authorization for Release of Medical?
To fill out the authorization, patients need to provide their personal information, specify the information to be released, identify the recipient, sign and date the form.
What is the purpose of Des Moines University Clinic Authorization for Release of Medical?
The purpose is to ensure that patients have control over their medical information and to facilitate communication between healthcare providers.
What information must be reported on Des Moines University Clinic Authorization for Release of Medical?
The form must include the patient's name, date of birth, type of information to be released, recipient details, and the patient's signature and date.
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