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Request for Records Release 114 Sandhill Dr. Suite 101 Middletown DE 19709 Tel. 302 378 4779 Fax 302 378 4789 PATIENT NAME DATE OF BIRTH ADDRESS LAST 4-DIGITS OF SSN Lax Dedhia MD Jill Mackey MD Haley Sparks PA-C Mini Mathew NP-C Michele Tjaden NP-C Megan Kerstetter F-NP PHONE FROM TO Physician/Facility Address Phone Fax INFORMATION TO BE RELEASED Complete Medical Records Recent H P Lab Reports Radiology Reports Hospital Reports Last 3 Visits REASON FOR THIS REQUEST Transfer of Care...
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How to fill out request for medical records

01
Gather all necessary personal information such as name, date of birth, address, and contact information.
02
Identify the healthcare provider or institution from which you are requesting the medical records.
03
Check the specific requirements of the healthcare provider regarding their medical records request process.
04
Prepare a written request stating your intention to obtain your medical records.
05
Include important details such as the type of records needed, specific dates or timeframes, and any specific medical conditions or treatments you want to be included in the records.
06
Sign and date the request letter.
07
Make copies of the request letter for your records.
08
Submit the request to the healthcare provider through their preferred method, which might include mailing, faxing, or visiting their office in person.
09
Follow up with the healthcare provider if you do not receive a response within a reasonable timeframe.
10
Keep a record of all communication and documentation related to your medical records request.

Who needs request for medical records?

01
Patients who want to access their own medical history and information.
02
Doctors and healthcare professionals who require the medical records of a patient for proper diagnosis and treatment.
03
Legal professionals who need medical records as evidence in a court case or for records review.
04
Insurance companies or government agencies for claims and eligibility verification purposes.
05
Researchers and academics studying health trends or conducting medical studies.
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A request for medical records is a formal application asking for a copy of a patient's health information.
Typically, a patient or their authorized representative is required to file a request for medical records.
To fill out a request for medical records, one must provide their personal information, details of the information requested, and sign a release form.
The purpose of a request for medical records is to obtain a copy of a patient's health information for personal use, legal matters, or healthcare purposes.
A request for medical records must include the patient's name, date of birth, medical record number (if available), specific information requested, and the purpose of the request.
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