Resurgens Authorization for Release of Medical Information free printable template

RESURGENS CENTRALIZED MEDICAL RECORDS 270 Chastain Road Kennesaw GA 30144 Telephone 678-594-6100 Fax 678-459-3166 Medical Record No. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PATIENT IDENTIFICATION Name Date of Birth S.S. last four digits only Maiden/Other names known by RELEASE RECORDS TO Person or Place records should be sent RECORDS REQUESTED PURPOSE OF RELEASE Address City/State/Zip Phone Fax Medical records Films Billing statement Other Dates to be included dates seen or time...

How to fill out Resurgens Authorization for Release of Medical Information

How to fill out Resurgens Authorization for Release of Medical Information

1. Obtain the Resurgens Authorization for Release of Medical Information form from the appropriate source, such as the Resurgens website or a medical office.
2. Fill out the patient's personal information, including name, date of birth, and contact details.
3. Specify the purpose of the release of medical information, such as continuing care or insurance claims.
4. Identify the specific medical information to be released, including dates and types of records needed.
5. Provide the name of the person or organization that will receive the information.
6. Sign and date the form to authorize the release of the medical records.
7. Submit the completed form to the designated medical office or organization.

Who needs Resurgens Authorization for Release of Medical Information?

1. Patients who wish to share their medical information with another healthcare provider.
2. Insurance companies that require medical records for processing claims.
3. Legal representatives or attorneys who need medical records for legal purposes.
4. Family members or guardians who need access to a patient's medical information for coordination of care.

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What is Resurgens Authorization for Release of Medical Information?

Resurgens Authorization for Release of Medical Information is a legal document that permits healthcare providers to share a patient's medical records and information with designated individuals or entities.

Who is required to file Resurgens Authorization for Release of Medical Information?

Patients seeking to have their medical information shared with other healthcare providers, insurance companies, or third parties are required to file the Resurgens Authorization for Release of Medical Information.

How to fill out Resurgens Authorization for Release of Medical Information?

To fill out the Resurgens Authorization for Release of Medical Information, a patient should complete the required fields, including their personal information, the specific medical records to be released, the recipients of the information, and the purpose for the release. The patient must also sign and date the form.

What is the purpose of Resurgens Authorization for Release of Medical Information?

The purpose of Resurgens Authorization for Release of Medical Information is to ensure that patient privacy is maintained while allowing necessary medical information to be shared with authorized parties to facilitate treatment, payment, or other healthcare-related activities.

What information must be reported on Resurgens Authorization for Release of Medical Information?

The information that must be reported on the Resurgens Authorization for Release of Medical Information includes the patient's name, date of birth, the specific medical records being released, the names of recipients, the purpose of the release, and the patient's signature and date.