Get the free Records Request/Release Form - Stonebrooke Family Physicians
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Dr. Ronald Bellisario Dr. Matthew Wald Dr. Stacey Last Dr. Jennifer Heiner Phone: (248×9979700 Fax: (248×9979707 MEDICAL RECORDS REQUEST PATIENT NAME’S): D.O.B PATIENT NAME’S): D.O.B PATIENT
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How to fill out records requestrelease form
How to fill out a records request/release form:
01
Start by providing your personal information, such as your name, address, and contact information, in the designated fields on the form.
02
Identify the type of records you are requesting or releasing by selecting the appropriate category or providing specific details.
03
Specify the purpose of your request/release by explaining why you need the records or what they will be used for.
04
If there are any specific records or documents you are requesting/releasing, make sure to provide as much detail as possible, such as names, dates, or any other identifying information.
05
Indicate the format in which you prefer to receive/submit the records, whether it's physical copies, digital files, or both.
06
If there are any fees associated with the request/release, make sure to include the payment or indicate your preferred method of payment.
07
Sign and date the form to certify the accuracy of the information provided.
08
Keep a copy of the completed form for your records.
Who needs a records request/release form:
01
Individuals who need access to their own personal records maintained by an organization or institution. This could be for various reasons, such as legal or personal purposes.
02
Lawyers or legal representatives who require access to relevant records for their clients' cases or legal matters.
03
Researchers or journalists who need access to specific records for academic or investigative purposes.
04
Employers or organizations that need to release certain records or information about an individual to comply with legal or regulatory requirements.
Remember, the specific circumstances and requirements may vary depending on the organization or institution handling the records, so it's always recommended to consult the provided instructions or reach out to the designated contact if you have any doubts or questions.
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