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Medical Record Release Request Form Patient Authorization for Use or Disclosure of Protected Health Information As required by the Health Portability and Accountability Act of 1996 (HIPAA) and Connecticut

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What is medical record release request?

A medical record release request is a form that authorizes the release of an individual's medical records from a healthcare provider. This form allows the patient to specify who can access their medical information.

Who is required to file medical record release request?

Anyone who wishes to obtain a copy of their medical records or authorize someone else to access their medical information is required to file a medical record release request.

How to fill out medical record release request?

To fill out a medical record release request, the individual must provide their personal information, specify the healthcare provider from whom they are requesting records, and indicate the purpose for which the information will be used.

What is the purpose of medical record release request?

The purpose of a medical record release request is to give individuals control over who can access their medical information and to ensure that their privacy is protected.

What information must be reported on medical record release request?

A medical record release request must include the patient's name, date of birth, contact information, the healthcare provider's name, and the specific records or information being requested.

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