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1 of 2 Medical Release Form (Minor) For Use and Disclosure of Protected Health Information (PHI) DMC Primary Care Attn: Medical Records Department 6 Sennett Road, Suite 100 Derry, NH 03038 6035371300Patients

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How to fill out authorization to release medical

01

Obtain the authorization form from the medical facility or request it through email or mail.

02

Fill out the patient's full name, date of birth, and any other identifying information requested on the form.

03

Specify the medical information that is being authorized for release.

04

Sign and date the form, and if necessary, have it witnessed or notarized.

05

Submit the completed authorization form to the medical facility either in person, via mail, or electronically.

Who needs authorization to release medical?

01

Anyone who is seeking to release their own medical information to a third party such as another medical provider, insurance company, or legal representative.

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What is authorization to release medical?

Authorization to release medical is a document that grants permission for the disclosure of an individual's medical information.

Who is required to file authorization to release medical?

Any individual or entity seeking to obtain a person's medical records is required to file authorization to release medical.

How to fill out authorization to release medical?

To fill out authorization to release medical, one must provide their personal information, specify the information to be released, and sign the document.

What is the purpose of authorization to release medical?

The purpose of authorization to release medical is to allow healthcare providers to release an individual's medical information to designated individuals or organizations.

What information must be reported on authorization to release medical?

The information that must be reported on authorization to release medical includes the individual's name, date of birth, specific information to be released, and the designated recipient.

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