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New Patient Information PERSONAL INFORMATION (Please Print) Name ___ Date ___ Date of Birth ___ Age ___ M / F Social Security #___ Address ___ StreetCityStateZipPhone: Home (___) ___ Work (___) ___
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How to fill out medical records release authorization

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How to fill out medical records release authorization

01
Obtain a copy of the medical records release authorization form from the healthcare provider or facility.
02
Fill out your personal information such as your name, date of birth, address, and contact information.
03
Specify the name of the healthcare provider or facility from which you are requesting the medical records.
04
Include the dates of treatment for which you are authorizing release of the medical records.
05
Sign and date the form to certify that you are authorizing the release of your medical records.
06
Submit the completed form to the healthcare provider or facility either in person, by mail, or by fax.

Who needs medical records release authorization?

01
Patients who want to request a copy of their own medical records for personal use.
02
Patients who are transferring their care to a new healthcare provider and need their medical records to be sent.
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Medical records release authorization is a legal document that grants permission for a healthcare provider to disclose a patient's medical information to a third party.
Typically, the patient or their legal representative is required to file medical records release authorization.
To fill out a medical records release authorization, the individual must provide their personal information, specify the records to be released, indicate the recipient, and sign the document.
The purpose of medical records release authorization is to protect patient privacy while allowing healthcare providers to share necessary medical information with authorized parties.
The information required includes the patient's name, date of birth, type of information being released, recipient's details, purpose of the release, and the patient's signature.
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