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9715 Medical Center Drive, Suite 530, Rockville, MD 20850 ObGynShadyGrove.com | Phone: (301) 7684535 | Fax: (301) 2798644MEDICAL RECORD REL EASE AUTHORIZE ACTION To: ___ Address: ___ I, ___, hereby
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How to fill out medical record release authorization

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How to fill out medical record release authorization

01
Obtain a medical record release authorization form from the healthcare provider or facility.
02
Fill out the patient's full name, date of birth, and contact information on the form.
03
Provide the name of the healthcare provider or facility from which the medical records are being requested.
04
Specify the dates of service for which you are requesting the medical records.
05
Sign and date the authorization form to give your consent for the release of your medical records.

Who needs medical record release authorization?

01
Individuals who wish to obtain copies of their own medical records for personal use.
02
Legal representatives who are authorized to request medical records on behalf of a patient.
03
Healthcare providers or facilities that need to share medical records with other providers for continuity of care.
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Medical record release authorization is a formal document that allows a healthcare provider to disclose a patient's medical records to a third party, such as another healthcare provider or an insurance company.
Patients or their legal representatives are required to file a medical record release authorization to permit healthcare providers to release their medical records.
To fill out a medical record release authorization, one must provide personal information, specify the information to be released, identify the recipient, and sign the document along with the date.
The purpose of medical record release authorization is to protect patient privacy while allowing the necessary sharing of health information for treatment, payment, or healthcare operations.
The information that must be reported includes patient identification, details of the records to be released, the purpose of the release, the recipient's information, and the patient's signature.
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