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This document serves as an authorization for the release of patient information from another organization to the University of Michigan Hospitals & Health Centers.

How to fill out request for outside records

How to fill out REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION

1. Obtain the REQUEST FOR OUTSIDE RECORDS form from the relevant organization.
2. Fill in the patient's full name, date of birth, and any other identifying information.
3. Provide the name and contact details of the organization or provider from whom the records are being requested.
4. Specify the type of records needed (e.g., medical history, treatment records, etc.).
5. Indicate the purpose of the request (e.g., ongoing treatment, legal reasons, etc.).
6. Sign and date the form to authorize the release of records.
7. Submit the completed form to the appropriate department of the organization.

Who needs REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

1. Patients seeking to obtain their medical records from another healthcare provider.
2. Healthcare professionals needing patient records for continuity of care.
3. Legal representatives requiring medical records for legal proceedings.
4. Insurance companies that need patient records for claim processing.

People Also Ask about

How do I word a request for medical records?

Making a health record access or correction request Your request should include: Your full name, address and date of birth. For access requests: a description of the information you're requesting and whether you require a summary, a full copy or if you want to view your records in person.

Can I release medical records from another facility?

Yes. If requested by an individual, a covered entity must transmit an individual's PHI directly to another person or entity designated by the individual.

How do I request someone else's medical records?

To receive a copy of your loved one's health records as a Personal Representative, you typically must ask for it in writing. In some cases, the hospital or doctor's office may have a form to request the records. Even with the legal right, however, this can prove to be a challenging process.

How do you write a formal request for medical records?

I was treated in your office [at your facility] between [fill in dates]. I request copies of the following [or all] health records related to my treatment. [Identify records requested (e.g., medical-history form you filled out; physician and nurses' notes; test results; consultations with specialists; referrals).]

For pdfFiller’s FAQs

What is REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

It is a formal document used to obtain medical records or patient information from an external healthcare provider or organization.

Who is required to file REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

Typically, healthcare providers, organizations, or authorized representatives of a patient are required to file this request when they need access to records from another healthcare entity.

How to fill out REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

The form should be completed by providing patient details, a specific request for information, the source of records, and required signatures to authorize the release.

What is the purpose of REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

The purpose is to facilitate the exchange of important patient information between healthcare providers for better coordination of care and to enhance patient treatment.

What information must be reported on REQUEST FOR OUTSIDE RECORDS - PATIENT INFORMATION FROM ANOTHER ORGANIZATION?

Required information typically includes patient identification details, specific records requested, purpose of the request, and signatures from the patient or their legal representative.