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Patient Request for Release of Films and Reports Solis Mammography Instructions to Patient Complete this document and send to Solis Mammography by scanning and emailing, or by faxing, to Solis by

How to fill out patient request for release

How to fill out a patient request for release:

1. Obtain the necessary forms: Start by obtaining the patient request for release form from the healthcare facility or organization where the patient's records are kept. This form is typically available on the facility's website or can be obtained in person.
2. Provide patient information: Begin by filling out the patient's personal information section on the form. This may include the patient's full name, date of birth, address, contact number, and social security number. Ensure that all information is entered accurately and legibly.
3. Specify the purpose of the release: Indicate the reason for the request for release. This can be for personal records, a second opinion, or transfer of care, among other possible reasons. Be clear and concise in stating the purpose of the release.
4. Identify the healthcare providers involved: Clearly list the names and contact information of the healthcare providers or facilities from which records need to be released. Include their addresses, phone numbers, and any other relevant contact details. Providing as much information as possible will help facilitate the release of the correct records.
5. Specify the dates and types of records: Specify the time period or specific dates for which the patient wants their records released. Additionally, identify the types of records needed, such as medical history, diagnostic reports, laboratory results, or treatment plans. This step ensures that only the necessary records are released.
6. Authorization signature: The patient or their legal representative must sign and date the release form to provide consent for the release of their medical records. This signature verifies that the patient understands and agrees to the terms and conditions of the release.
7. Witness and notary requirements: Some organizations may require a witness or notary to authenticate the patient's signature. Check the specific requirements of the healthcare facility or organization where the release is being requested and ensure compliance if necessary.

Who needs a patient request for release?

1. Patients seeking second opinions: Patients who wish to obtain a second opinion from another healthcare provider may be required to fill out a patient request for release. This allows the new provider to access the patient's previous medical records for a comprehensive assessment.
2. Patients transferring care: When changing healthcare providers or moving to a different location, patients may need to request their medical records for transfer. This ensures a continuity of care and allows the new provider to have a complete understanding of the patient's medical history.
3. Patients requesting personal records: Some individuals may want copies of their medical records for personal reference, documentation, or personal record-keeping purposes. By filling out a patient request for release, they can obtain their medical records for personal use.

Remember to consult the specific requirements and procedures of the healthcare facility or organization where the patient request for release is being submitted, as they may have additional instructions or variations in the process.

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