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PHONE: 847.382.5111 FAX: 847.382.8993 EMAIL: Info yourskinforlife.com MEDICAL RECORD RELEASE Please Print Clearly Patient Name Date of Birth / / I hereby authorize Van Dam Dermatology & Laser Center

How to fill out medical record release

To fill out a medical record release, follow these steps:

1. Obtain the necessary form: Start by acquiring the specific medical record release form from the healthcare provider or facility where your records are stored. You can usually find this form on their website, or you can request it in person or by phone.
2. Read the instructions carefully: Once you have the form, take the time to read the instructions thoroughly. Familiarize yourself with the purpose of the release, any limitations or exclusions, and any specific information required to complete the form correctly.
3. Provide personal information: Begin by filling out your personal information at the top of the form. This typically includes your name, address, date of birth, contact information, and any other identifiers requested. Ensure all the information is accurate and up to date.
4. Specify the purpose of the release: Indicate why you are requesting the release of your medical records. Common reasons include transferring to a new healthcare provider, applying for insurance benefits, legal proceedings, or personal records management. Be clear and concise in explaining the purpose.
5. Identify the timeframe: Determine the timeframe during which the medical records should be released. This can range from a specific date range to a single visit. Ensure you provide accurate dates to avoid any confusion or delays in processing your request.
6. Choose the appropriate authorization: Depending on your situation, you may need to authorize the release of your entire medical record or only certain portions of it. Specify whether you want all records released or if you have specific documents or information in mind (e.g., laboratory results, imaging reports, consultation notes).
7. Review and sign the form: Before submitting the form, carefully review all the information you have provided. Make sure it is accurate, complete, and error-free. Once satisfied, sign and date the form as required. If applicable, provide any additional required signatures, such as a parent's signature for a minor's records.
8. Keep a copy for your records: Make a copy of the completed form for your own records before submitting it to the healthcare provider. This will serve as proof of your request and provide you with a reference if any issues arise during the release process.

Who needs a medical record release?

A medical record release may be needed by individuals who require access to their own medical records or who need to authorize the release of their records to another party. Common scenarios where a medical record release is necessary include:

1. Transferring healthcare providers: When switching healthcare providers, it is often required to authorize the release of your medical records to ensure continuity of care and provide the new provider with a complete medical history.
2. Legal proceedings: In legal cases related to personal injury, medical malpractice, or disability claims, medical records often play a crucial role. Therefore, the relevant parties may need to request and obtain medical record releases to access the necessary documents.
3. Insurance purposes: When applying for certain types of insurance, such as life or health insurance, the insurer may require a medical record release to assess your health status or determine eligibility.
4. Personal records management: Some individuals may choose to maintain a personal record of their medical history for various reasons, such as managing their own health or sharing information with family members or caregivers.

Overall, anyone who needs access to their medical records or wishes to authorize the release of these records to a third party will require a medical record release form.

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