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Release of Medical Information Authorization 374 E. Grand Ave. Mail Code 6740 Carbondale, IL 62901 P: 618-453-3311 F: 618-453-4452 she.six.edu Patient Name Local Phone ID # Date Of Birth Release From

How to fill out release of medical information

How to fill out the release of medical information:

1. Obtain the necessary form: Contact the healthcare provider or facility from which you require your medical records and request the release of medical information form. They may provide it in person, through email, or have it available on their website for download.
2. Review the form carefully: Read through the form to understand the information it requires and any instructions provided. Pay attention to any specific sections or fields that need to be filled out.
3. Personal information: Begin by filling out your personal information accurately. This typically includes your full name, date of birth, address, contact number, and any other details specified on the form.
4. Specify the purpose: Identify the reason for requesting the release of medical information. This could be for personal records, legal purposes, insurance claims, or to transfer your medical information to another healthcare provider.
5. Specify the recipient: Indicate the name and contact information of the individual or organization that should receive your medical records. This could be your new healthcare provider, an attorney, or any other authorized recipient.
6. Timeframe for release: Mention the specific dates or timeframe for which the medical information should be released. You can either specify a specific start and end date or state it as an ongoing authorization until further notice.
7. Sign and date: Once you have filled out all the required information, carefully read through the form again to make sure everything is correct. Then, sign and date the form to confirm your consent for the release of your medical information.
8. Witness or notary: Some release of medical information forms may require a witness or notary signature for added validity. Check the instructions provided and arrange for a witness or notary if necessary.

Who needs release of medical information:

1. Patients transferring healthcare providers: When switching doctors or medical facilities, it is often essential to provide your new healthcare provider with your medical history. A release of medical information allows for the transfer of your records, ensuring continuity of care.
2. Legal proceedings: Attorneys may require access to your medical records for legal cases, such as personal injury claims, medical malpractice lawsuits, or disability applications. A release of medical information grants them permission to request and review these records.
3. Insurance claims: When filing insurance claims, especially for significant medical expenses, insurance companies may request access to your medical records to verify the treatment and determine coverage. A release of medical information allows them to retrieve the required information.
4. Family members or caretakers: In certain situations, such as when a patient is unable to handle their medical affairs due to illness or incapacitation, a release of medical information may be necessary to grant access to family members or designated caretakers who can make informed decisions on their behalf.

Note: The specific individuals or organizations that may need a release of medical information can vary depending on personal circumstances and legal requirements. It is always recommended to consult with the healthcare provider or legal professionals for guidance tailored to your situation.

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