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Request for Specific External Medical Records(This form is for University Healthcare Alliance (UHF). Continuing Care use only when requesting records from outside providers.)DATE: TO:___ Name of Healthcare

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How to fill out release of info request

01

Contact the organization or healthcare provider that you want to release your information to

02

Request a release of information form

03

Fill out the form completely with accurate information

04

Specify the type of information that you want to release

05

Sign and date the form

06

Submit the form either in person, by mail, fax, or through the organization's secure online portal

Who needs release of info request?

01

Individuals who want to authorize the release of their personal information to a specific organization or individual

02

Healthcare providers who need access to a patient's medical records for treatment purposes

03

Insurance companies who require medical information for processing claims

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What is release of info request?

The release of info request is a formal document used to authorize the disclosure of an individual's protected health information.

Who is required to file release of info request?

Any individual who wishes to authorize the disclosure of their protected health information is required to file a release of info request.

How to fill out release of info request?

To fill out a release of info request, one must provide their personal information, specify the information to be disclosed, and sign the authorization form.

What is the purpose of release of info request?

The purpose of a release of info request is to allow individuals to control who has access to their protected health information and to ensure the privacy of their medical records.

What information must be reported on release of info request?

The release of info request must include the individual's personal information, the specific information to be disclosed, and the recipient of the information.

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