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Get the free Medical Records Release - Fort Worth

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Patient Name: ___ Date of Birth: ___/___/___ ALLOW COMMUNICATION to and from the below PROVIDER and Girls to Women Health & Wellness, Young Men Health and Wellness, our in house licensed therapists/dietitians
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How to fill out medical records release

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How to fill out medical records release

01
Obtain the medical records release form from the healthcare provider or facility.
02
Fill in your personal information including full name, date of birth, and contact information.
03
Specify the dates of the records you are requesting and the purpose for the release.
04
Sign and date the form to authorize the release of your medical records.
05
Submit the completed form to the healthcare provider or facility either in person, by mail, or through their online portal.

Who needs medical records release?

01
Individuals who want to request their own medical records for personal use or to share with another healthcare provider.
02
Authorized representatives who are acting on behalf of someone else such as a parent requesting records for a minor child or a legal guardian requesting records for an incapacitated adult.
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Medical records release is a process by which a patient authorizes the disclosure of their medical information to a third party.
The patient or their legal guardian is required to file a medical records release form.
To fill out a medical records release form, the patient must provide their personal information, the information of the party receiving the records, and sign and date the authorization.
The purpose of medical records release is to give permission for healthcare providers to share medical information with other parties involved in the patient's care.
The medical records release must include the patient's name, date of birth, contact information, the information to be disclosed, and the purpose of the disclosure.
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