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LAKE WASHINGTON YOUTH SOCCER ASSOCIATION 12525 Willows Road NE, Suite 100, Kirkland, WA 98034 Phone: 4258211741 Fax: 4258200702 MEDICAL RELEASE FORM Parents: Complete this form and return it to your
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How to fill out a medical release form1:

01
Begin by writing your personal information, including your full name, date of birth, and contact details.
02
Provide information about your healthcare provider, such as their name, address, and phone number.
03
Indicate the specific medical records or information you are authorizing the release of by checking the relevant boxes.
04
Specify the purpose for which the medical information will be released, such as for insurance claims or for consultation with another healthcare provider.
05
Sign and date the form, certifying that you understand the implications of releasing your medical information.
06
If you are filling out the form on behalf of someone else, include their name, relationship to you, and your authority to act on their behalf.

Who needs medical release form1?

01
Individuals who are seeking a transfer of their medical records from one healthcare provider to another.
02
Patients who are undergoing treatment or consultation with multiple healthcare providers and need their medical information to be shared between them.
03
Individuals applying for insurance coverage or making a claim that requires the release of their medical information.
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A medical release form1 is a document that grants permission to healthcare providers to release medical information about an individual to a specified person or entity.
The individual for whom the medical information is being released is required to file the medical release form1.
To fill out a medical release form1, the individual must provide their personal information, specify who the information is being released to, and sign the form to authorize the release of their medical information.
The purpose of a medical release form1 is to authorize the release of an individual's medical information to a specified person or entity for a specific purpose.
The information that must be reported on a medical release form1 includes the individual's personal information, the information being released, the purpose of the release, and the recipient of the information.
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