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Robert Wiesenthal, M.D. John Seen, M.D. Xiaomi Wang, M.D. Christopher Shims, O.D. CONSENT FOR RELEASE OF PERSONAL HEALTH INFORMATION (PHI) Patients Name:Date of Birth:Maiden Name:Phone #(if applicable)I
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01
Obtain a copy of the records release form titled 'records-release-form-camillusdoc'
02
Read through the form carefully to understand the required information and sections
03
Start by filling out your personal information, such as your name, address, and contact details
04
Provide any necessary identification details, such as your date of birth or social security number
05
Indicate the specific records you are requesting to be released, providing as much detail as possible, such as the dates, types of records, and any relevant case numbers
06
If there are any specific individuals or organizations you want the records to be released to, include their contact information and relationship to you, if applicable
07
Sign and date the form at the designated area to certify that the information provided is accurate and that you authorize the release of the records
08
Make a copy of the complete form for your records before submitting it
09
Submit the filled-out form according to the instructions provided, whether it's by mail, fax, or in person
10
Follow up with the relevant department or organization to confirm receipt of the form and to inquire about any additional steps or information required for the records release process

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Anyone who wishes to request the release of specific records from Camillusdoc needs to fill out the 'records-release-form-camillusdoc'. This form is required to authorize the release of the requested records and provide necessary identification and contact details. The form ensures that only authorized individuals or organizations have access to the requested records.
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The records-release-form-camillusdoc is a document used to authorize the release of medical records or other confidential information to a designated recipient.
Any individual who wishes to release their medical records or other confidential information to a third party is required to file the records-release-form-camillusdoc.
To fill out the records-release-form-camillusdoc, one must provide their personal information, specify the information to be released, and designate the recipient of the information.
The purpose of the records-release-form-camillusdoc is to authorize the release of confidential information to a designated party for a specific purpose.
The records-release-form-camillusdoc must include the individual's personal information, the specific information to be released, and the recipient of the information.
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