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Pentahealth FAX: 6105942625AUTHORIZATION FOR RELEASE, USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION *Patient Name:*Date of Birth:*Address:Phone #*I authorize×Phone×TO RELEASE MY MEDICAL RECORDS
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To fill out the pentahealth-medical-records-release-form, follow these steps: 1. Start by entering your personal information, including your full name, date of birth, address, phone number, and email address.
02
Indicate the purpose of the request by selecting the appropriate option. For example, if you need the medical records for personal use, choose 'Personal'.
03
Specify the exact dates of the medical records you want to request. Provide the starting and ending dates if applicable.
04
In the 'Medical Providers' section, list the healthcare providers or facilities from which you are requesting the records. Include their names, addresses, and contact information.
05
Sign and date the form to acknowledge that you authorize the release of your medical records.
06
If necessary, provide any additional information or instructions in the 'Additional Notes' section.
07
Make a copy of the completed form for your records and submit the original to the designated recipient, either by mail or in person.

Who needs pentahealth-medical-records-release-form?

01
Anyone who requires access to their medical records from PentaHealth should fill out the pentahealth-medical-records-release-form. This may include patients who are transferring care to a new healthcare provider, applying for disability benefits, or participating in research studies that require medical history documentation.
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The pentahealth-medical-records-release-form is a document used to authorize the release of an individual's medical records to a designated third party.
Patients or their legal representatives are required to file the pentahealth-medical-records-release-form to obtain their medical records.
To fill out the pentahealth-medical-records-release-form, individuals need to provide their personal information, specify the records needed, identify the recipient of the records, and sign the form.
The purpose of the pentahealth-medical-records-release-form is to legally permit healthcare providers to disclose a patient's medical records while ensuring patient privacy and compliance with regulations.
The information that must be reported includes the patient's name, date of birth, details of the medical records requested, recipient's information, and the patient's signature.
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