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Granville Pediatrics Jeffrey S. Mantra, MD Kim l. Alt, MD Crew J. Stravinsky, DO 2845 44th St SW Ste 200 Granville, MI 49418 P# 6165382410 F# 6165381557 AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

How to fill out release of record form

How to fill out a release of record form:

1. Start by entering your personal information at the top of the form. This includes your full name, address, phone number, and any other requested contact information.
2. Next, indicate the specific records you are requesting to be released. Provide clear details about the type of records (medical, educational, employment, etc.) and any specific dates or time frames involved.
3. In the "Purpose" section, explain why you are requesting these records. Are you seeking medical treatment with a new provider? Applying for a job or educational program? Make sure to be concise and specific in explaining your purpose.
4. If applicable, provide the name and contact information of the person or organization to whom you would like the records to be released. This could be a healthcare provider, educational institution, employer, or any other relevant party.
5. Read through the form carefully and sign it at the bottom. By signing, you are acknowledging your request and giving permission for the records to be released as specified.
6. Make a copy of the completed form for your own records before submitting it to the appropriate person or organization.

Who needs a release of record form:

1. Patients who are switching healthcare providers may need a release of record form to transfer their medical history and treatment records from one provider to another.
2. Students applying to colleges or universities may need to submit a release of record form to request their academic transcripts from previous schools.
3. Job seekers who are asked to provide a comprehensive employment history may need to fill out a release of record form to authorize the release of their employment records from previous employers.
4. Individuals involved in legal proceedings, such as lawsuits or insurance claims, may need to complete a release of record form to allow relevant records to be shared with the involved parties.
5. Individuals participating in research studies may be required to fill out a release of record form to grant permission for their data and personal information to be used and shared as outlined in the study protocols.

For pdfFiller’s FAQs

What is release of record form?

A release of record form is a legal document that allows an individual or organization to authorize the disclosure of certain records or information to a third party.

Who is required to file release of record form?

The individual or organization who wants to release certain records or information to a third party is required to file a release of record form.

How to fill out release of record form?

To fill out a release of record form, the individual or organization will need to provide their contact information, details of the records or information being released, and specify the recipient of the information.

What is the purpose of release of record form?

The purpose of a release of record form is to legally authorize the disclosure of specific records or information to a designated third party.

What information must be reported on release of record form?

The release of record form must include details such as the type of records or information being released, the reason for the release, and the identity of the recipient.

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