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Received: Completed: By: East South St George Utah Phone Mail Fax AUTHORIZATION TO RELEASE MEDICAL INFORMATION Patient Full Name (PRINT) DOB Address City State Zip The above patient authorizes Snow
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01
First, obtain a copy of the medical records release062615doc form.
02
Read the form carefully, making sure you understand all the information and instructions provided.
03
Fill in your personal information accurately, including your full name, date of birth, and contact information.
04
Provide information about the healthcare provider or facility from which you are requesting medical records.
05
Specify the dates or time frame for which you are requesting the records.
06
Indicate the purpose for which you need the medical records, such as for personal use or for transferring to another healthcare provider.
07
Review the completed form to ensure all information is correctly filled out and there are no errors or missing details.
08
Sign and date the form to authorize the release of your medical records.
09
Submit the form to the healthcare provider or facility according to their preferred method, such as in person, by mail, or through an online portal.
10
Keep a copy of the completed form for your records.

Who needs medical records release062615doc?

01
Individuals who want to access their own medical records.
02
Patients who are transferring to a new healthcare provider and need their medical records to be sent.
03
Insurance companies or legal entities requiring medical records for claims or legal proceedings.
04
Researchers or academic institutions conducting medical studies.
05
Family members or authorized representatives acting on behalf of a patient.
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2015 1996 Utah HIPAA Schlagel PFT Hardin Hallenborg Portability Accountabilty EMG redisclose Esplin EEG Schmidt dba DOB authorizes applicable providers Neurology Dependency revoke MD specified disclosed DISCLOSURE expiration forwarding recipient generated

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