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Cary Rheumatology & Arthritis Associates PA 1720 NW Maynard Road Cary, NC 27513 9193440180 (P) 9198511900 (F) Authorization to Release Medical Information Patient Name Gender Male Female D.O. B Address
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How to fill out authorization-to-release-medical-info

01
Step 1: Obtain the authorization-to-release-medical-info form from the healthcare provider or facility.
02
Step 2: Read the instructions carefully to understand the purpose and scope of the authorization.
03
Step 3: Fill in your personal information, including your full name, date of birth, address, and contact information.
04
Step 4: Specify the recipient(s) of the medical information by providing their names, addresses, and contact information.
05
Step 5: Clearly state the purpose for which the medical information is being released.
06
Step 6: Specify the date range or time period for which the authorization is valid.
07
Step 7: Review the completed form for accuracy and completeness.
08
Step 8: Sign and date the form.
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Step 9: Submit the completed form to the healthcare provider or facility.
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Step 10: Keep a copy of the signed authorization for your records.

Who needs authorization-to-release-medical-info?

01
Authorization-to-release-medical-info is typically needed by individuals who wish to authorize the release of their medical information to a specific person, organization, or entity.
02
This may include patients who want their medical records sent to another healthcare provider, insurance companies, legal representatives, or any other parties involved in their healthcare or legal matters.
03
The specific need for authorization can vary depending on the individual's circumstances and requirements.
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Authorization-to-release-medical-info is a legal document that allows a healthcare provider to disclose a patient's medical information to a specified third party.
Typically, a patient or their legal representative is required to file authorization-to-release-medical-info to permit the release of their healthcare records.
To fill out the authorization-to-release-medical-info, the individual must complete all required fields, including patient information, the specific information to be released, the purpose of the release, and the date of signature.
The purpose of authorization-to-release-medical-info is to ensure that patient health information is disclosed lawfully and to protect patient privacy.
Information that must be reported includes the patient’s name, contact information, the specific medical records to be released, the name of the individual or organization receiving the information, and the patient's signature.
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