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33 Chestnut Street Elbert on, Ga. 30635 Phone: 7062132580 Fax: 7065222143MEDICAL RECORDS RELEASEAuthorization for Release of Protected Health Information Patient\'s full name at the time of treatment:
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How to fill out medical records release request

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How to fill out medical records release request

01
Obtain the necessary medical record release form from the healthcare provider or facility.
02
Fill out your personal information, including full name, date of birth, and contact information.
03
Specify the exact medical records you are requesting by providing the dates of service, types of records, and specific healthcare providers.
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.
06
Follow up with the provider to ensure that your request has been processed and the records are sent to the designated recipient.

Who needs medical records release request?

01
Patients who are transferring to a new healthcare provider and need to share their medical history.
02
Insurance companies or legal entities requiring medical records for claims processing or legal proceedings.
03
Family members or designated representatives managing the healthcare needs of a loved one.
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A medical records release request is a formal document that authorizes the release of an individual's medical information to another party.
The patient or their legal guardian is required to file a medical records release request in order to authorize the release of medical information.
To fill out a medical records release request, one must provide their personal information, specify the information to be released, and indicate the intended recipient.
The purpose of a medical records release request is to ensure that an individual's medical information is only disclosed with proper authorization.
The medical records release request must include the patient's name, date of birth, specific information to be released, recipient's name and address, and signature of the patient or guardian.
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