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Dr. Saw Htun, MD AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION Please print___ Patient NameOther Last Names___ Date of birthPhone NumberEmail Address___ Street AddressCity, State, Zip codeTransfer
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How to fill out medical-record-authorization-release

01
Obtain a copy of the medical record authorization release form from the healthcare provider or facility.
02
Fill in your personal information, including your full name, date of birth, address, and contact information.
03
Specify the specific healthcare provider or facility that you are authorizing to release your medical records.
04
Indicate the purpose for which the records are being released, such as for personal use or to be sent to another healthcare provider.
05
Sign and date the form to indicate your consent for the release of your medical records.
06
Submit the completed form to the healthcare provider or facility as per their instructions.

Who needs medical-record-authorization-release?

01
Anyone who wishes to authorize a healthcare provider or facility to release their medical records may need a medical record authorization release form. This could include individuals who are transferring care to a new provider, seeking a second opinion, applying for insurance benefits, or involved in a legal matter where medical records are relevant.
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A medical record authorization release is a legal document that allows healthcare providers to disclose a patient's medical information to a designated individual or entity.
The patient or their designated representative is typically required to file a medical record authorization release.
To fill out a medical record authorization release, you must provide patient information, specify the records to be released, indicate the recipient, and sign and date the form.
The purpose of a medical record authorization release is to grant permission for the sharing of a patient's medical information between healthcare providers or with other authorized entities.
Essential information required includes the patient's name, address, date of birth, the specific medical records being requested, the name of the recipient, and the patient's signature.
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