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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS (Scanned copy to be kept in chart) c Send records TO c Release to SHARE information Print Patient Name: Previous Name (if applicable): Last 4 digits of

How to fill out release of medical records

How to fill out a release of medical records:

1. Obtain the necessary form: Start by obtaining the release of medical records form. You can request this form from your healthcare provider's office or download it from their website. Make sure you have the correct form as different healthcare providers may have slightly different versions.
2. Read the instructions: Before filling out the form, carefully read the instructions provided. This will ensure that you understand what information is required and how to correctly complete the form.
3. Personal information: Begin by providing your personal information, such as your name, date of birth, address, and contact details. This information will help identify you and ensure that the correct medical records are released.
4. Release specifics: Indicate the specific medical records that you want to be released by clearly stating the name of your healthcare provider(s), the dates of treatment or records you are requesting, and any specific information you are seeking.
5. Authorization: Sign and date the authorization section of the form, giving your consent for the release of your medical records. It's important to ensure that you are legally authorized to request these records, especially if you are filling out the form on behalf of someone else.
6. Witnesses and notary: In some cases, the release of medical records form may require witnesses or a notary public to validate your signature. Check the form instructions to see if this is necessary. If witnesses are required, have them sign and include their contact information.
7. Submitting the form: Once you have completed the form, make copies for your records. Next, follow the instructions provided on how and where to submit the form. This may involve returning the form to your healthcare provider's office, sending it through mail, or submitting it online if possible.

Who needs a release of medical records?

1. Patients seeking specialized care: When you are referred to a specialist, doctors often need access to your complete medical history. By signing a release of medical records, you allow your primary care provider to share your records with the specialist, ensuring the best quality of care.
2. Insurance claims: If you need to file an insurance claim, you may be required to provide your medical records to support your claim. By completing a release of medical records, you grant permission for your healthcare provider to share the necessary records with your insurance company.
3. Legal matters: In legal situations such as personal injury lawsuits or disability claims, access to your medical records may be necessary. By signing a release of medical records, you authorize the release of your records to the appropriate legal entities involved in your case.
4. Research purposes: Medical researchers may require access to medical records to study certain conditions or develop new treatments. By signing a release of medical records, you allow your healthcare provider to share your records for research purposes while maintaining your privacy and confidentiality.

Note: The specific circumstances and requirements for a release of medical records may vary depending on the healthcare provider and jurisdiction. Always consult with your healthcare provider or legal professional for guidance specific to your situation.

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