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59 One Mile Road East Windsor, NJ 08520 Phone: 6094434500 Fax: 6094260530 CONSENT FOR RELEASE OF MEDICAL RECORDS AND USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION TO A THIRD PARTY, (Name and

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How to fill out record release to us

01

To fill out the record release form, follow these steps:

02

Start by entering your personal information such as your name, address, and contact details.

03

Provide the details of the medical record you want to release, including the name of the healthcare provider or facility, the dates of treatment, and any specific records or documents you need.

04

Specify the purpose of releasing the records. For example, indicate if you need them for personal use, to transfer to a new healthcare provider, or for legal purposes.

05

Read and understand the authorization statement carefully before signing the form. Make sure you agree to the terms and conditions mentioned.

06

Date and sign the form to certify that you are providing your consent for the release of your medical records.

07

If required, provide the name and contact information of the person or organization to whom the records should be released.

08

Keep a copy of the completed form for your records.

09

Note: It is important to consult with the healthcare provider or facility to ensure you are using the correct record release form and to understand any specific requirements they may have.

Who needs record release to us?

01

Various individuals or entities may need a record release form, including:

02

- Patients who want to obtain copies of their medical records for personal use or to share with other healthcare providers.

03

- Healthcare providers or facilities who need to transfer a patient's records to another provider for continuing care.

04

- Legal professionals who require medical records as evidence in a court case.

05

- Insurance companies that need medical records to process claims.

06

- Researchers or academic institutions conducting medical studies and requiring access to patient records (with appropriate consent and privacy safeguards).

07

Please note that the specific need for a record release form may vary depending on the country or jurisdiction.

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