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Authorization for Use and Disclosure of Patient Health Information 2300 53rd Avenue Bettendorf, IA 52722 Fax (563) 3240615520 Valley View Drive Moline, IL 61265 Fax (309) 76236906101 Northwest Blvd
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01
Obtain a copy of the medical records release form-0917pdf from the healthcare provider or download it online.
02
Fill in your personal information such as your full name, date of birth, and address.
03
Provide details of the healthcare provider from whom you are requesting the medical records, including their name, address, and contact information.
04
Specify the dates of the medical records you are requesting and the purpose of the release.
05
Sign and date the form to authorize the release of your medical records.
06
Make a copy of the completed form for your records before submitting it to the healthcare provider.

Who needs medical-records-release-form-0917pdf?

01
Individuals who want to request a copy of their medical records from a healthcare provider.
02
Legal representatives or designated individuals who have been authorized to access someone else's medical records.
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This form is used to authorize the release of medical records.
The patient or their legal guardian is required to file this form.
The form must be completed with the patient's information, the purpose of the release, and any specific records to be released.
The purpose of this form is to give permission for medical records to be shared with another party, such as a healthcare provider or insurance company.
The form will require the patient's name, date of birth, contact information, the healthcare provider's information, and the records to be released.
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