Get the free Record release form - Bonnie Sunday, MD home page

Bonnie Sunday MD General Physician PC Phone (716) 253-6005 Fax (716) 771-1690 Office Address 2701 Transit Road Suite 143 Elma, NY 14059 REQUEST MEDICAL RECORDS (PLEASE PRINT) I hereby request and

How to fill out record release form

How to fill out a record release form:

1. Start by reading the form thoroughly to understand the required information and any instructions provided.
2. Begin by providing your personal details, such as your full name, address, and contact information.
3. If applicable, provide the name and contact information of the healthcare facility or organization that is requesting the records.
4. Specify the purpose for the release of records, whether it is for personal use, legal matters, medical treatment, or other purposes.
5. Clearly state the date range or specific dates for which you are authorizing the release of records.
6. Identify the specific types of records you are authorizing to be released, such as medical records, lab reports, X-rays, or any other relevant information.
7. Indicate whether you would like the records to be released in person, via mail, fax, or electronically.
8. Review the form for accuracy and completeness before signing and dating it.
9. If the form requires a witness or notary, ensure that this requirement is fulfilled.
10. Make a copy of the completed form for your records before submitting it to the appropriate party.

Who needs a record release form:

1. Patients: Individuals who want to request copies of their medical records for personal use, further medical treatment, or legal purposes.
2. Healthcare Providers: Medical professionals or organizations that need to obtain a patient's records for continued care, referral to specialists, or to meet legal or regulatory requirements.
3. Insurance Companies: Insurance providers may request record release forms to verify claims, assess eligibility, or investigate fraudulent activities.
4. Attorneys or Legal Representatives: Lawyers or legal representatives may require access to medical records for litigation, personal injury claims, or to support legal proceedings.
5. Researchers or Government Agencies: Researchers or government agencies may need access to medical records for statistical analysis, public health purposes, or policy development.

Please note that the specific requirements and regulations governing the use and release of medical records may vary by country and jurisdiction. It is important to consult relevant laws and regulations to ensure compliance when filling out record release forms.

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