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OUTGOING RECORDS RELEASE AUTHORIZATION I HEREBY AUTHORIZE GPM PEDIATRICS, PC TO RELEASE MY CHILD/CHILDREN MEDICAL RECORDS TO: NAME:___ ADDRESS:___ CITY, STATE, ZIP:___ PHONE NUMBER/FAX (IF KNOWN)___GPM

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How to fill out outgoing records release authorization

01

Obtain the necessary release authorization form from the appropriate source (e.g. healthcare provider, legal office, etc.)

02

Fill out the personal information section accurately including full name, date of birth, and address

03

Specify the records being requested for release and the purpose for which they are being requested

04

Sign and date the form to authorize the release of the records

05

Submit the completed form to the designated recipient either in person, by mail, or by fax

Who needs outgoing records release authorization?

01

Individuals who need to access their own medical records for personal use or to share with another healthcare provider

02

Legal representatives who require medical records for legal proceedings or to assist their clients

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What is outgoing records release authorization?

Outgoing records release authorization is a form that allows an individual or organization to release records to a third party.

Who is required to file outgoing records release authorization?

Anyone who wishes to release records to a third party is required to file outgoing records release authorization.

How to fill out outgoing records release authorization?

To fill out outgoing records release authorization, you must provide the necessary information about the records being released and the recipient.

What is the purpose of outgoing records release authorization?

The purpose of outgoing records release authorization is to ensure that records are released to the correct recipient in a secure and authorized manner.

What information must be reported on outgoing records release authorization?

The outgoing records release authorization must include details about the records being released, the recipient's information, and the reason for the release.

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