Get the free Release of Info request (CPC) Outside Records Request.docx
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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
How to fill out release of info request
01
Obtain a copy of the release of info form.
02
Fill out the form completely and accurately with your personal information.
03
Provide specific details about the information you are requesting to be released.
04
Sign and date the form, acknowledging that you authorize the release of the information.
05
Submit the completed form to the appropriate person or organization, following their specific instructions for submission.
Who needs release of info request?
01
Individuals requesting their own medical records or information
02
Legal representatives or executors handling the affairs of someone who is deceased
03
Insurance companies requiring medical information for claims processing
04
Employers conducting background checks or verifying employment history
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What is release of info request?
Release of info request is a formal document that authorizes the disclosure of an individual's protected health information.
Who is required to file release of info request?
The individual or their legal representative is required to file a release of info request in order to authorize the disclosure of their protected health information.
How to fill out release of info request?
To fill out a release of info request, the individual needs to provide their personal information, specify who can disclose the information, and for what purpose the information can be disclosed.
What is the purpose of release of info request?
The purpose of release of info request is to give individuals control over who can access their protected health information and for what purpose.
What information must be reported on release of info request?
The release of info request must include the individual's name, date of birth, the information to be disclosed, the purpose of the disclosure, and the recipient of the information.
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