Get the free Medical Record Release Form - Mercy

Mercy Clinic Cancer Care 7607 S. New Balls, Suite 3300 St. Louis, MO 63141 phone 314-251-4400 fax 314-251-6375 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Patient Identification Printed

How to fill out medical record release form

How to fill out a medical record release form:

1. Begin by obtaining the correct form: Contact the medical facility or healthcare provider where your records are stored and ask for a medical record release form. They may provide it to you in person, by mail, or have it available for download on their website.
2. Read the instructions carefully: Once you have the form in hand, make sure to carefully read through the instructions provided. This will ensure that you understand the process and any specific requirements that need to be followed.
3. Provide your personal information: Begin by filling out the top section of the form which will typically ask for your personal information. This may include your full name, date of birth, contact information, and social security number. Make sure to double-check the accuracy of the information before proceeding.
4. Specify the medical records you wish to release: In the main section of the form, you will need to specify the exact medical records you wish to release. This could include specific dates, treatments, diagnoses, or the complete medical history. Be as specific as possible to ensure the correct records are released.
5. Indicate the purpose of the release: In this section, you will need to state the purpose for which you are requesting the release of your medical records. Common reasons may include transferring to a new healthcare provider, sharing with another medical professional, or for personal records.
6. Specify who the records will be released to: In this section, you will need to provide the name and contact information of the individual, organization, or healthcare provider to whom you want your medical records released. Make sure to include accurate contact details to ensure delivery.
7. Sign and date the form: After completing all the necessary sections, carefully review the form for any errors or omissions. Once satisfied, sign and date the form in the designated area. In some cases, you may also need to have your signature witnessed or notarized, so be sure to check the instructions provided on the form.

Who needs a medical record release form:

1. Patients transferring to a new healthcare provider: When switching healthcare providers, it is common for the new provider to request a copy of your medical records for a smooth transition. A medical record release form may be required in this case.
2. Individuals seeking a second opinion: If you are seeking a second opinion from a different healthcare professional, they may request your medical records to review your past treatments, diagnoses, and any relevant information.
3. Legal purposes: In some legal situations, such as a personal injury or medical malpractice case, both the plaintiff and defendant may need to request the release of medical records as part of the legal proceedings.
4. Insurance claims: When filing an insurance claim, especially for medical treatments or procedures, the insurance company may require access to your medical records to verify the nature and necessity of the treatment.
5. Employers conducting pre-employment screenings: Some employers may require applicants to sign a medical record release form as part of the pre-employment screening process, particularly if the job involves physical fitness or positions that require knowledge of a candidate's medical history.

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What is medical record release form?

The medical record release form is a document that allows the release of an individual's medical information to a specified party, such as another healthcare provider or insurance company.

Who is required to file medical record release form?

The patient or authorized representative is required to fill out and file the medical record release form.

How to fill out medical record release form?

To fill out the medical record release form, the patient or authorized representative must provide their personal information, specify the information to be released, and sign the form.

What is the purpose of medical record release form?

The purpose of the medical record release form is to ensure the privacy and confidentiality of an individual's medical information while allowing the transfer of information to authorized parties.

What information must be reported on medical record release form?

The medical record release form must include the patient's name, date of birth, contact information, the information to be released, the recipient's information, and the purpose of the release.