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RELEASE OF MEDICAL RECORD INFORMATION 4822 Six Forks Road, Ste. 104 Raleigh, NC 27609 Phone: (919) 8034188 Fax: (919) 8034117 Release to Live Well Primary Care This authorization expires ninety (90)

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How to fill out release of medical record

01

Gather all relevant information

02

Download or obtain the release of medical record form

03

Read and understand the form

04

Complete the patient information section

05

Specify the medical records to be released

06

Provide any additional required information

07

Sign and date the form

08

Submit the completed form as instructed

Who needs release of medical record?

01

Patients who want to release their medical records to another healthcare provider

02

Patients who need their medical records for legal purposes

03

Patients who are changing healthcare providers and want their medical history transferred

04

Patients who want access to their own medical records for personal reasons

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What is release of medical record?

Release of medical record is a legal document that allows healthcare providers to release a patient's medical information to a third party.

Who is required to file release of medical record?

Healthcare providers are required to file release of medical record in order to disclose a patient's medical information.

How to fill out release of medical record?

To fill out release of medical record, you must provide information such as patient's name, date of birth, specific information to be released, reason for release, and recipient of the information.

What is the purpose of release of medical record?

The purpose of release of medical record is to protect the privacy of patient's medical information while allowing healthcare providers to share necessary information for treatment and other purposes.

What information must be reported on release of medical record?

The information reported on release of medical record includes patient's personal information, specific medical information to be released, reason for release, and recipient of the information.

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