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17500 N. Perimeter Dr., Scottsdale, AZ 85255 Patient Name: DOB: Address: Phone: I hereby authorize FREEDOM PAIN HOSPITAL to RELEASE copies of the following medical records: H&P Consult Reports Lab
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How to fill out FPH medical record release:

01
Locate the FPH medical record release form. This form is usually provided by the healthcare institution or facility where you are receiving or have received medical treatment.
02
Begin by reading the instructions carefully. Make sure you understand the purpose of the form and what information will be released.
03
Fill in your personal information accurately. This typically includes your full name, date of birth, current address, and contact information.
04
Provide the dates of your medical treatment. Specify the exact time period for which you are authorizing the release of your medical records.
05
Clearly state which medical records you want to be released. You may want to be specific and mention certain types of records or specific healthcare providers.
06
Indicate the purpose for releasing your medical records. You might be authorizing the release for insurance claims, continuing care with another healthcare provider, or legal purposes.
07
Carefully review the release form before signing it. Ensure that all the information provided is accurate and complete.
08
Sign and date the form. By signing, you are legally authorizing the release of your medical records for the specified purpose.

Who needs FPH medical record release?

01
Patients who are transferring their care to a new healthcare provider may need to fill out an FPH medical record release form. This allows the new provider to access the patient's medical history and make informed decisions regarding their care.
02
Individuals who are involved in legal proceedings and require access to their medical records for evidence or documentation may also need the FPH medical record release form.
03
Insurance companies may request the FPH medical record release form to review and process claims related to the patient's medical treatment.
Overall, anyone who wants their medical records to be shared with another party or organization will need to fill out the FPH medical record release form. It is important to ensure that the form is filled out accurately and signed appropriately to comply with legal and privacy regulations.
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