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Cares Community Health 1500 21st Street Sacramento, CA 95811 www.carescommunityhealth.org (916) 9146305 Medical Record Fax Number: 9163251984 REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS
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01
Ensure that you have a copy of the CARES Community Health 1500 form.
02
Start by entering the patient's information in section 1. This includes their name, address, and contact information.
03
In section 2, provide the patient's birth date, gender, and social security number.
04
Move to section 3 and fill in the appropriate insurance information. This includes the primary insurance company's name, policy number, and group number.
05
If there is secondary insurance, fill in the details in section 4.
06
Section 5 requires you to provide information about the patient's condition and whether it is related to employment, auto accident, or other accident.
07
In section 6, indicate whether the patient has any other health insurance coverage.
08
Section 7 is for the treatment authorization and physician's or supplier's information. Fill in the necessary details here.
09
Proceed to section 8 and provide details about the referring physician if applicable.
10
Section 9 is for the signature, date, and additional information.
11
Review the completed form for any errors or missing information before submitting it.
12
Once filled out completely, you can submit the CARES Community Health 1500 form to the appropriate entity.

Who needs cares community health 1500?

01
Healthcare providers and facilities that provide services to patients covered by CARES program need the CARES Community Health 1500 form.
02
Insurance agencies and companies processing healthcare claims require this form to ensure accurate billing and reimbursement.
03
Patients receiving medical services through the CARES program may also need to fill out this form to provide necessary information for insurance coverage and claims processing.
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Cares Community Health 1500 is a form used by healthcare providers to report information about the care provided to patients.
Healthcare providers who have provided care to patients are required to file Cares Community Health 1500.
To fill out Cares Community Health 1500, healthcare providers must provide information about the services provided, patient demographics, and billing details.
The purpose of Cares Community Health 1500 is to collect data on healthcare services provided to patients for reporting and billing purposes.
Information such as patient demographics, services provided, billing codes, and insurance information must be reported on Cares Community Health 1500.
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