Get the free Release of Medical Record - Progressive Medical Clinic

PROGRESSIVE MEDICAL CLINIC, LLP 11920 Astoria Blvd., Suite 300 Houston, Texas 77089 Phone: (281) 481-8878 Fax: (281) 481-9020 www.progmd.com AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION PATIENT

How to fill out release of medical record

How to fill out a release of medical record:

1. Obtain the release form: Contact the healthcare provider or facility from where you want to request the medical records. Request the release form, which may be available on their website or can be sent to you via email, fax, or mail.
2. Read the instructions carefully: Once you have the release form, take the time to read the instructions thoroughly. Make sure you understand what information is required and any specific guidelines that need to be followed.
3. Fill in personal information: Start by filling in your personal information accurately. This typically includes your full name, date of birth, address, phone number, and any other requested contact details.
4. Specify the purpose of the release: Indicate the specific purpose for which you are requesting the medical records. This could be for personal use, legal proceedings, insurance claims, or transfer to a new healthcare provider.
5. Provide details of the healthcare provider/facility: Write the name, address, and contact information of the healthcare provider or facility from where you want the medical records to be released. Include any additional information they may require, such as specific departments or healthcare professionals.
6. Specify the records to be released: Clearly state the timeframe or date range for the medical records you want to access. You can typically request specific documents, such as lab results, imaging reports, treatment summaries, or the complete medical record.
7. Authorization and signature: Sign and date the release form to officially authorize the release of your medical records. If the request is for someone other than yourself, ensure you have the necessary legal authority or obtain the patient's consent if applicable.
8. Submit the release form: Follow the instructions provided on the release form to submit it back to the healthcare provider or facility. Check if they require the form to be mailed, faxed, emailed, or submitted in person.

Who needs a release of medical record?

1. Patients: Individuals who want to access their own medical records may need to fill out a release form. This could be for personal use, to gain insights into their medical history, or to share with a new healthcare provider.
2. Authorized representatives: In certain situations, a legal guardian, power of attorney holder, or designated representative may need to fill out a release form on behalf of the patient. This applies if the patient is a minor, incapacitated, or unable to provide consent themselves.
3. Third parties: Other entities or individuals, such as insurance companies, attorneys, or government agencies, may require a release form to obtain a patient's medical records for purposes related to legal matters, insurance claims, or healthcare assessments.

Remember, the specific requirements for filling out a release of medical record form may vary depending on the healthcare provider, facility, or jurisdiction. It's essential to carefully review their instructions and seek assistance if needed to ensure accurate completion of the form.

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