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RELEASE OF INFORMATION REQUEST Associated Costs Any Report $0.25 per page CD / DVD $10 Flash Drive $15 An additional charge for postage and envelope will be charged if the record(s) are to be mailed.
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How to fill out release of information request
How to fill out release of information request
01
Obtain the release of information request form from the organization or health care provider.
02
Fill out your personal information, including your name, address, and date of birth.
03
Clearly state the information you are requesting to be released.
04
Specify the purpose of the release and how the information should be sent (fax, email, mail, etc.).
05
Sign and date the form to authorize the release of information.
06
Review the completed form for accuracy before submitting it to the organization.
Who needs release of information request?
01
Individuals who need to request their own medical records from a healthcare provider.
02
Insurance companies or legal representatives who require medical records for processing claims or legal cases.
03
Employers who need to verify an individual's medical history for workplace safety or insurance purposes.
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What is release of information request?
Release of information request is a formal request to authorize the disclosure of protected health information to a specified party.
Who is required to file release of information request?
Any individual or organization seeking access to protected health information is required to file a release of information request.
How to fill out release of information request?
Release of information request forms can typically be obtained from healthcare providers or facilities and must be filled out completely and accurately.
What is the purpose of release of information request?
The purpose of release of information request is to ensure that individuals have control over who can access their protected health information.
What information must be reported on release of information request?
Release of information request forms typically require the individual's name, date of birth, the information to be disclosed, the recipient of the information, and the purpose of the disclosure.
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