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Revised 6/17/16Campus Health & Wellbeing California Polytechnic State University San Luis Obispo, CA 934070210 Office (805) 7561211 Fax (805) 7565298 Please print. Must be completed in authorization

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How to fill out authorization to release records

01

Obtain the authorization to release records form from the healthcare provider or institution.

02

Fill in the patient's full name, date of birth, and any other identifying information requested.

03

Specify the records that are being authorized for release (e.g. medical records, lab results, treatment notes).

04

Include the recipient's name and contact information where the records should be sent.

05

Sign and date the form, indicating your consent for the release of records.

06

Make a copy of the completed form for your records before submitting it to the healthcare provider or institution.

Who needs authorization to release records?

01

Anyone who wishes to authorize the release of their medical records to a third party, such as another healthcare provider, insurance company, attorney, or family member.

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What is authorization to release records?

Authorization to release records is a legal document that allows a person or entity to access and share another individual's records, such as medical, financial, or educational information.

Who is required to file authorization to release records?

Typically, individuals or organizations that need access to another person's records, such as healthcare providers, legal representatives, or financial institutions, are required to file authorization to release records.

How to fill out authorization to release records?

To fill out authorization to release records, one must provide the necessary details, including the person's name whose records are being requested, the specific records needed, the purpose for the request, and the signatures of all relevant parties.

What is the purpose of authorization to release records?

The purpose of authorization to release records is to ensure consent is obtained before disclosing personal information, protecting confidentiality, and complying with legal regulations.

What information must be reported on authorization to release records?

The information that must be reported includes the names of the parties involved, the type of records being released, the duration of the authorization, the purpose of the release, and signatures of the individual whose records are being released.

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