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Medical Record Number:Authorization for Release of Medical Information
Name of Patient:
Number to call:
Date of Request:Date of Birth:
()Call when ready? (Circle) yes no(Circle) Pick up or Mail or
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To fill out a number to call, follow these steps:
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Begin by dialing the international access code for your country (usually 00 or +).
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Note: Be sure to remove any leading zeros from the area or city code and local phone number.
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What is number to call?
Number to call is a specific phone number that can be used to contact a particular individual or organization.
Who is required to file number to call?
Anyone who needs to provide a contact number for a specific purpose may be required to file a number to call.
How to fill out number to call?
To fill out a number to call, simply enter the phone number that you want to use as the contact number.
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The purpose of a number to call is to provide individuals with a way to contact a particular person or organization.
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The information that must be reported on a number to call includes the phone number itself and any relevant details about the purpose of the number.
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