Brown University Medical Record Request 2017-2025 free printable template

Health Services Box 1928 Providence, RI 02912 4018633953 Medical Record Request/Release Authorization Section 1 Name: ID #: Date of Birth: Phone #: Section 2 Allow Brown Health Services and Counseling

How to fill out Brown University Medical Record Request

How to fill out Brown University Medical Record Request

1. Obtain the Brown University Medical Record Request form from the university's website or medical office.
2. Complete the personal information section, including your full name, date of birth, and contact information.
3. Specify the dates of service for which you are requesting records.
4. Indicate the purpose of the request (e.g., personal use, transfer to another healthcare provider).
5. Sign and date the form to authorize the release of your medical records.
6. Submit the completed form via mail, fax, or in person to the designated medical records office at Brown University.

Who needs Brown University Medical Record Request?

1. Current or former students who wish to access their medical records.
2. Healthcare providers needing medical information for ongoing patient care.
3. Insurance companies requiring medical documentation for claims.
4. Individuals requesting their records for personal health management.

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What is Brown University Medical Record Request?

The Brown University Medical Record Request is a formal process through which individuals can request access to their personal medical records held by Brown University's healthcare facilities.

Who is required to file Brown University Medical Record Request?

Individuals who wish to access their own medical records, including students, alumni, and former patients of Brown University healthcare services, are required to file a Brown University Medical Record Request.

How to fill out Brown University Medical Record Request?

To fill out the Brown University Medical Record Request, individuals should complete the designated request form, providing their personal details, the specific records requested, and sign the form to authorize the release of their medical information.

What is the purpose of Brown University Medical Record Request?

The purpose of the Brown University Medical Record Request is to ensure that individuals have the legal right to access their medical records and to facilitate the sharing of their health information, as required by law.

What information must be reported on Brown University Medical Record Request?

The information that must be reported on the Brown University Medical Record Request includes the requester's full name, date of birth, contact information, specifics of the records requested, and a signature for authorization.