Get the free Medical Record Release Form - Denver Physical Therapy

PATIENT NUMBER DATE DENVER PHYSICAL THERAPY, P.C. MEDICAL RECORDS DEPARTMENT NO & STREET 7310 S. Alton Way, Suite 6L ? Englewood, Colorado 80112 303/573-5800 ext 20 phones ? 303/573-1155 fax CITY

How to fill out medical record release form

How to fill out a medical record release form:

1. Obtain a copy of the medical record release form from the healthcare provider or facility. This form is typically available online, at the provider's office, or can be requested via mail.
2. Read the instructions on the form carefully. It is important to understand the purpose and scope of the release before proceeding.
3. Provide your personal information in the designated sections of the form. This includes your full name, date of birth, address, and contact details. Make sure all the information is accurate and up to date.
4. Specify the healthcare provider or facility from which you want your medical records to be released. Include the name, address, and any relevant identification numbers, if provided on the form.
5. Indicate the dates of service or the specific timeframe for which you are requesting the medical records. This helps the provider retrieve the relevant information efficiently.
6. Review any additional options or authorizations provided on the form. For example, you may have the option to request a specific format for your records or authorize the release of sensitive information, such as psychiatric records.
7. Sign and date the form in the designated areas. By signing, you are confirming that you understand and authorize the release of your medical records as outlined on the form.
8. Keep a copy of the completed form for your records. It is always a good idea to have a copy of any documents you sign or send, in case there are any issues or discrepancies in the future.

Who needs a medical record release form?

1. Individuals who are changing healthcare providers and want their medical records transferred to the new provider.
2. Patients who are seeking a second opinion or consulting with a specialist may need to authorize the release of their medical records to the consulting physician.
3. Insurance companies and legal professionals may require medical records as part of a claims process or legal proceedings.
4. Patients who are participating in a research study or clinical trial may need to provide a medical record release form to the study coordinator or institution.
5. Family members or legal representatives who are acting on behalf of a patient, such as a parent of a minor or someone with power of attorney, may need to complete a medical record release form to access the patient's records.

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