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Grant Memorial Hospital PO Box 1019 Petersburg, WV 26847 Telephone (304)2571026 Fax (304)2571923Release of Information Authorization Form ___ Name of Patient___ Date of Birth___ ___ SSN (last 4 digits)

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How to fill out grant memorial hospital release

01

Obtain the Grant Memorial Hospital release form from the hospital or their website.

02

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

03

Provide details about your medical history and the reason for requesting the release.

04

Sign and date the form to certify that the information provided is accurate.

05

Submit the completed form to the hospital's records department or follow their specific instructions for submission.

Who needs grant memorial hospital release?

01

Patients who have received treatment at Grant Memorial Hospital and need their medical records transferred to another healthcare provider.

02

Individuals who require a copy of their medical records for personal use or legal purposes.

03

Authorized representatives acting on behalf of a patient who is unable to request the release themselves.

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What is grant memorial hospital release?

Grant memorial hospital release refers to the formal authorization given by a patient or their legal representative to allow the hospital to release their medical information.

Who is required to file grant memorial hospital release?

Any patient or their legal representative who wishes to authorize the release of their medical information from Grant Memorial Hospital.

How to fill out grant memorial hospital release?

To fill out a grant memorial hospital release form, the patient or their legal representative must provide their personal information, specify the information to be released, and sign the document.

What is the purpose of grant memorial hospital release?

The purpose of grant memorial hospital release is to allow the hospital to share the patient's medical information with authorized individuals or entities, such as other healthcare providers or insurance companies.

What information must be reported on grant memorial hospital release?

The grant memorial hospital release form must include the patient's name, date of birth, contact information, the specific information to be released, the duration of authorization, and the signature of the patient or their legal representative.

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