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Authorization to Release/Obtain Medical Information Last Name: First Name: DOB: Phone Number: Email: I hereby authorize Lake shore Health Partners and Holland Hospital Medical Groups to disclose and/or
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How to fill out authorization to releaseobtain medical
How to fill out authorization to releaseobtain medical
01
Read the authorization form carefully to understand what information you are authorizing to be released or obtained.
02
Provide your personal information including full name, address, date of birth, and contact information.
03
Specify the medical information that you wish to be released or obtained.
04
Mention the purpose of the release or obtainment of medical information.
05
State the period of time for which the authorization is valid.
06
Include any additional instructions or limitations regarding the release or obtainment of medical information.
07
Sign and date the authorization form.
08
Submit the completed authorization form to the appropriate medical facility or healthcare provider.
Who needs authorization to releaseobtain medical?
01
Patients who wish to authorize the release of their medical information to another person or entity.
02
Patients who want to obtain medical records or information from a healthcare provider or medical facility.
03
Individuals who are acting on behalf of a patient and require access to the patient's medical information.
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