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Release of Information 3340 Providence Dr., Ste. 452 Anchorage, AK 99508 Phone: 9075622120 Fax: 9075626527Patient Name: Parent/Guardian Name (if patient is under 18): Date of Birth: Phone Number:Address:
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How to fill out AK LaTouche Pediatrics Release of Information

01
Obtain the AK LaTouche Pediatrics Release of Information form from the clinic's website or request a copy in person.
02
Fill out the patient's personal information, including name, date of birth, and contact information.
03
Specify the information you wish to be released by checking the appropriate boxes, such as medical records, billing records, or other specific documents.
04
Indicate the purpose of the release, such as for referral, insurance purposes, or personal records.
05
List the recipient's name and contact information, ensuring it is clear who will receive the information.
06
Sign and date the form to authorize the release of information.
07
Submit the completed form to AK LaTouche Pediatrics either in person, via mail, or electronically if supported.

Who needs AK LaTouche Pediatrics Release of Information?

01
Patients who want to share their medical information with another healthcare provider.
02
Parents or guardians needing to obtain information regarding their child's medical history.
03
Individuals seeking to access their own medical records for personal or legal reasons.
04
Insurance companies that require medical documentation for claims processing.
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AK LaTouche Pediatrics Release of Information is a formal document that allows the healthcare provider to share a patient's medical information with specified individuals or organizations.
The patient or their legal guardian is required to file the AK LaTouche Pediatrics Release of Information in order to authorize the release of medical records.
To fill out the document, provide personal information such as the patient's name and date of birth, specify the information to be released, indicate who will receive the information, and sign and date the form.
The purpose is to ensure that medical information is shared with authorized parties while protecting the patient's privacy and complying with legal regulations.
The information that must be reported includes the patient's identifying details, the specific medical records or types of information to be released, the name of the recipient, and any expiration date of the authorization.
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