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Student Health Services IIT Tower, Suite 3D9-1 10 W. 35th Street Chicago, IL 60616 Phone: 312 567 7550 Fax: 312 567 5702 Email: student. Health IIT.edu AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

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What is medical record release form?

A medical record release form is a document that allows the release of an individual's medical records from a healthcare provider to another authorized person or organization.

Who is required to file medical record release form?

The patient or the legal guardian of the patient, depending on the situation, is required to file the medical record release form.

How to fill out medical record release form?

To fill out a medical record release form, you need to provide your personal information, such as name, date of birth, address, and contact details. You also need to specify the healthcare provider from where the records will be released and the authorized recipient of the records. Additionally, you may need to mention the specific dates or types of medical records to be released.

What is the purpose of medical record release form?

The purpose of a medical record release form is to authorize the disclosure of an individual's medical information to a specific person or organization. It allows healthcare providers to share necessary medical records with other healthcare professionals involved in the patient's care or with insurance companies, legal authorities, or any other authorized entity.

What information must be reported on medical record release form?

The medical record release form typically requires the reporting of the patient's personal information (name, date of birth, address), the specific healthcare provider or facility that holds the records, the recipient of the records, and any specific details regarding the dates or types of records to be released.

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