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Mammogram Records Release Form Today's Date: GW Account# Patient Name: DOB Dr / / SSN / / I authorize the release of original Mammogram images on CD or REPORTS as specified below: FROM: MAIL TO: Facility

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How to fill out ctoa-mammo-release-of-records-form-2012

How to Fill out ctoa-mammo-release-of-records-form-2012:

01

Begin by entering your personal information in the designated fields, including your full name, address, and contact details.

02

Provide your date of birth and social security number, as requested. This information is necessary to correctly identify your medical records.

03

Ensure that you have accurately filled out the section regarding your healthcare provider. Include their name, address, and contact information to facilitate the release of your records.

04

Specify the dates of the medical records you wish to have released. This can include a specific timeframe or a range of dates. Be as detailed as possible to ensure the correct documents are provided.

05

Indicate the purpose for which you require the records. This may include personal health history, second opinion, legal proceedings, or insurance claims. Clearly state the reason to facilitate the processing of your request.

06

Sign and date the form in the designated spaces to confirm your authorization for the release of your medical records.

07

Keep a copy of the completed form for your records and submit the original to the relevant healthcare provider.

Who needs ctoa-mammo-release-of-records-form-2012?

01

Individuals who have previously received mammograms or breast imaging services and wish to have their records released.

02

Patients seeking a second opinion from another healthcare provider, such as a specialist or a different radiologist.

03

Individuals involved in legal proceedings, such as personal injury cases or medical malpractice claims, who require access to their medical records for evidence.

04

Patients who are changing healthcare providers and need their medical records transferred to the new healthcare facility.

05

Individuals submitting insurance claims related to mammograms or breast imaging and need their medical records to support their claim.

Note: It is important to consult the instructions provided with the specific form and any additional requirements or guidelines from the healthcare provider when filling out the ctoa-mammo-release-of-records-form-2012 form.

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