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Phone 9199384404 Fax 9199383055 MEDICAL RECORDS RELEASE Patient Name: Date of Birth: Patient Social Security Number: Release Records to: Name Address, City, State & Zip () () Phone Number Fax number

How to fill out medical records release for

How to fill out a medical records release form:

1. Start by entering your personal information such as your full name, date of birth, and contact information.
2. Next, provide the name and contact information of the healthcare provider or facility you would like to release your medical records from.
3. Specify the dates or time frame for which you would like your medical records to be released. You can indicate a specific start and end date, or you may choose to release records from a certain period of time (e.g., the past two years).
4. Determine the purpose of the release. Specify whether you need the records for personal use, insurance purposes, legal matters, or any other specific reason.
5. If applicable, indicate who is authorized to receive the records. This could be yourself, a specific individual, or an organization. Make sure to include their full name, relationship to you (if applicable), and their contact information.
6. Read the terms and conditions of the release form carefully. Understand what you are consenting to and any limitations on the release of information. If you have any questions or concerns, it is advisable to seek clarification from the healthcare provider or facility.
7. Sign and date the form. Make sure to provide your full legal signature, as well as the date on which you are signing the release form.
8. If required, submit the form to the appropriate healthcare provider or facility. Some may allow you to submit the form electronically, while others may require you to mail or hand-deliver the form.

Who needs a medical records release form?

1. Patients who are transferring their medical care to a new healthcare provider may need to fill out a medical records release form in order to have their previous medical records sent to the new provider for continuity of care.
2. Individuals who are participating in legal proceedings, such as a personal injury lawsuit or workers' compensation claim, may require their medical records to support their case. In such instances, a medical records release form may be necessary to authorize the release of the records to the appropriate parties involved.
3. Insurance companies may require a medical records release form from policyholders in order to verify claims or determine eligibility for coverage.
4. Researchers or other authorized organizations may require access to specific medical records for the purpose of a study or assessment. A medical records release form would be needed to obtain the necessary information.

It is important to remember that the need for a medical records release form can vary depending on the individual's circumstances, and it is always best to consult with the healthcare provider or facility involved for guidance on their specific requirements.

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