Get the free Medical Record Release Authorization Form - MedPeds - medpeds

Medical Record Release Authorization 7350 Van Duse Road Suite 130, Laurel, Maryland 20707 Phone: (301)-498-8880 Fax: (301)-498-7939 Patient Name Maiden Name SS# Date of Birth Home Phone Cell/Work

How to fill out medical record release authorization

How to Fill Out Medical Record Release Authorization:

1. Begin by obtaining the medical record release authorization form from your healthcare provider or hospital. This form may be available online, in person, or through mail depending on their policies.
2. Carefully read through the form and make sure you understand each section and its purpose. Contact your healthcare provider if you have any questions or need clarification.
3. Provide your personal information as requested on the form, including your full name, date of birth, address, and contact information. This information ensures that the correct medical records are identified and released.
4. Specify the purpose of the medical record release by indicating whether it is for your own personal use, for another healthcare provider, for legal proceedings, or for any other purpose. Be as detailed as possible to ensure proper release.
5. Indicate the specific medical records you would like to authorize for release. This could include medical history, laboratory results, specialist consultations, imaging reports, and any other relevant documents. You may have the option to authorize the release of all records or limit it to specific periods or types of records.
6. Identify the healthcare providers or institutions that are authorized to release your medical records. This should include the names, addresses, and contact information of all parties involved.
7. Include the dates or timeframe during which the authorization is valid. You may set a specific end date or state that the authorization is valid until revoked in writing.
8. Carefully review the entire form to ensure all information is accurate and complete. Make any necessary corrections or additions before signing and dating the form.
9. In some cases, the form may require the presence of a witness or notary public. If necessary, arrange for the appropriate person to witness your signature or notarize the document.
10. Keep a copy of the completed and signed medical record release authorization for your records. Submit the original form to your healthcare provider or follow their instructions for submission.

Who Needs Medical Record Release Authorization:

1. Patients who wish to access their own medical records for personal use or to share with another healthcare provider.
2. When transitioning to a new healthcare provider, it is common for them to request medical record release authorization in order to obtain your past medical history.
3. Individuals involved in legal proceedings, such as a personal injury lawsuit or disability claim, may need to authorize the release of their medical records to support their case.
4. Insurance companies or government agencies may require medical record release authorization to process claims or determine eligibility for benefits.
5. Family members or legal guardians who require access to a patient's medical records, with the appropriate authorization, may also need to complete this process. This is often the case for minors, elderly individuals, or those who are incapacitated.

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