Des Moines University Clinic Authorization for Release of Medical Information 2018-2025 free printable template

Des Moines University Clinic, H.I.M. Dept. 3200 Grand Avenue, Des Moines, IA 50312 Phone (515) 2711700 Fax (515) 2711726 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I give permission to use and/or

How to fill out Des Moines University Clinic Authorization for Release

How to fill out Des Moines University Clinic Authorization for Release of Medical

1. Obtain the Authorization for Release of Medical form from Des Moines University Clinic.
2. Fill out the patient’s full name and date of birth at the top of the form.
3. Specify the dates of treatment or the specific records you are requesting.
4. Provide the name of the person or organization to whom the records should be released.
5. Indicate how the records should be delivered (e.g., mail, fax, in-person pick-up).
6. Sign and date the form to authorize the release of your medical information.
7. Include any additional information requested on the form, such as your address or contact number.

Who needs Des Moines University Clinic Authorization for Release of Medical?

1. Patients who want to share their medical records with another healthcare provider.
2. Patients applying for insurance or disability benefits that require medical history.
3. Individuals who are involved in legal matters that require access to medical records.

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What is Des Moines University Clinic Authorization for Release of Medical?

Des Moines University Clinic Authorization for Release of Medical is a legal document that allows the clinic to share a patient's medical information with designated individuals or organizations.

Who is required to file Des Moines University Clinic Authorization for Release of Medical?

Generally, any patient who wishes to have their medical information shared with another party must file the Des Moines University Clinic Authorization for Release of Medical.

How to fill out Des Moines University Clinic Authorization for Release of Medical?

To fill out the form, patients need to provide their personal information, specify the information to be released, identify who will receive it, and sign and date the document.

What is the purpose of Des Moines University Clinic Authorization for Release of Medical?

The purpose of the authorization is to ensure that patients have control over their medical information and can grant permission for its disclosure to other parties.

What information must be reported on Des Moines University Clinic Authorization for Release of Medical?

The authorization must include the patient's name, contact information, specific medical records to be released, name of the recipient, and the purpose for sharing the information.