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RELEASEOFMEDICALRECORDS
AtlantaChildrensClinicalCenter, P.C.
455EastPacesFerryRoadSuite212
Atlanta,GA30305
[phone:404.261.2666][fax:404.261.2669]
Irequestthat
AtlantaChildrensClinicalCenter, P.C.,
releasethemedicalrecordsandimmunizationdates
ofthefollowingpatients:
(Pleaselistthefullnamesofallchildrenwhomyouarerequestingrecordsfor.)
1.
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How to fill out release of medical records
How to fill out release of medical records
01
Obtain the release of medical records form from the healthcare provider or facility.
02
Fill out your personal information such as name, date of birth, address, and contact information.
03
Specify the dates of the medical records you are requesting to be released.
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 fax.
Who needs release of medical records?
01
Patients who want to request a copy of their medical records for personal use or to share with another healthcare provider.
02
Insurance companies or legal representatives who require medical records for claims or legal proceedings.
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What is release of medical records?
Release of medical records is the process of allowing healthcare providers to share a patient's medical information with other entities.
Who is required to file release of medical records?
Both healthcare providers and patients may be required to file release of medical records, depending on the situation.
How to fill out release of medical records?
To fill out a release of medical records, one must typically provide their personal information, specify the information to be released, and sign the authorization.
What is the purpose of release of medical records?
The purpose of release of medical records is to ensure the proper sharing of medical information for treatment, payment, or healthcare operations.
What information must be reported on release of medical records?
The release of medical records must include the patient's name, date of birth, medical record number, specific information to be released, and the purpose of the release.
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