Get the free MEDICAL RECORD RELEASE FORM

MEDICAL RECORD/IMAGE RELEASE FORM INSTRUCTIONS: Complete this form in its entirety and forward or fax to: RAA Imaging High Resolution Albuquerque Imaging Center 4411 The 25 Way NE, Suite 150 Albuquerque,

How to fill out medical record release form

How to fill out a medical record release form:

1. Start by obtaining the form: The first step is to obtain a copy of the medical record release form. You can usually do this by contacting the healthcare provider or facility where your medical records are held. Some providers may also have the form available on their website for download.
2. Provide your personal information: The form will typically require you to provide your personal information, such as your full name, date of birth, and current address. Make sure to fill in this information accurately to ensure that your medical records are properly identified.
3. Specify the records you want to release: Indicate in the form which specific medical records you would like to release. This can include a particular timeframe (e.g., records from the past two years) or specific types of records (e.g., laboratory results, consultation notes, or imaging reports).
4. State the purpose of the release: You may be asked to provide a brief explanation of why you are requesting the release of your medical records. This could be for personal reference, to share with another healthcare provider, or for legal reasons.
5. Include the recipient's information: Provide the contact information of the individual or organization who will be receiving your medical records. This could be another healthcare provider, an insurance company, or yourself. Double-check the recipient's details to ensure accuracy.
6. Review and sign the form: Carefully review all the information you have provided in the form. Make any necessary corrections or additions before signing it. By signing the form, you are giving your consent for the release of your medical records as specified.

Who needs a medical record release form?

1. Patients requesting their own records: If you want to access your own medical records, you may need to complete a medical record release form. This ensures that your medical information is shared with only authorized individuals or entities.
2. Individuals transferring care or seeking a second opinion: When changing healthcare providers or seeking a second opinion, it is often necessary to share your medical records with the new provider. A medical record release form allows for the smooth transfer of your medical information.
3. Legal proceedings: In certain legal situations, such as personal injury claims or disability applications, medical records may be required as evidence. To facilitate this process, a medical record release form can be used to authorize the release of relevant medical information.

It is important to note that the need for a medical record release form may vary depending on local regulations and specific circumstances. It is always best to consult with your healthcare provider or legal counsel if you have any doubts or questions about the process.

For pdfFiller’s FAQs

What is medical record release form?

A medical record release form is a document that authorizes healthcare providers to release a patient's medical records to designated individuals or organizations.

Who is required to file medical record release form?

The patient or their legal guardian is required to file a medical record release form.

How to fill out medical record release form?

To fill out a medical record release form, the patient or legal guardian must provide their personal information, specify the healthcare provider releasing the records, and designate who the records will be released to.

What is the purpose of medical record release form?

The purpose of a medical record release form is to ensure that patient confidentiality is maintained while allowing authorized individuals or organizations access to the patient's medical information.

What information must be reported on medical record release form?

The medical record release form must include the patient's name, date of birth, healthcare provider's information, and the names of individuals or organizations authorized to receive the records.

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