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Release of Records Form Henry Fertility Michael A. Henry, M.D. Patient authorization for copy and release of records from Henry Fertility I, (Name of Patient)(Address of Patient)(Date of Birth)(SS
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How to fill out patient authorization for copy
How to fill out patient authorization for copy
01
Obtain the patient authorization for copy form from the healthcare facility or their website.
02
Fill out the patient's personal information such as name, date of birth, and medical record number.
03
Specify the type of information being requested to be copied.
04
Sign and date the form as the authorized representative of the patient or have the patient sign it themselves if they are able.
05
Submit the completed form to the healthcare facility's medical records department.
Who needs patient authorization for copy?
01
Individuals who need copies of a patient's medical records or information for legal reasons, insurance claims, or personal use.
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