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GEORGETOWN BEHAVIORAL HEALTH INSTITUTE RELEASE OF INFORMATION REQUEST FORM DISCLOSURE: I, hereby authorize Georgetown Behavioral Health Institute to release and discuss medical records, (including

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How to fill out release of information request

01

Obtain the release of information form from the organization or facility that maintains your records.

02

Fill out your personal information such as name, date of birth, address, and contact information.

03

Specify the information you want to release and the purpose for which it will be used.

04

Sign and date the form to authorize the release of information.

05

If necessary, provide any additional supporting documentation or identification.

06

Submit the completed form to the organization or facility according to their designated process.

Who needs release of information request?

01

Individuals who want to authorize the release of their personal information to another party.

02

Healthcare providers who need to share medical records with other healthcare professionals or facilities.

03

Legal representatives who require access to confidential information for legal purposes.

04

Employers who need to verify an employee's background or work history.

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What is release of information request?

Release of information request is a formal document that authorizes the disclosure of a person's protected health information to a specified individual or entity.

Who is required to file release of information request?

Individuals or entities seeking access to someone's protected health information are required to file a release of information request.

How to fill out release of information request?

To fill out a release of information request, one must provide their personal information, specify the information to be released, and authorize the disclosure to a specific recipient.

What is the purpose of release of information request?

The purpose of a release of information request is to ensure that protected health information is disclosed only to authorized individuals or entities for a specific purpose.

What information must be reported on release of information request?

The release of information request must include the requester's personal information, the specific information to be disclosed, and the name of the authorized recipient.

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