Get the free Release of Medical Information Form - CT.gov

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION Patient Name: ___ Date of Birth: ___ I authorize the State of Connecticut, Department of Public Health (DPH) to disclose the health information

How to fill out release of medical information

How to fill out release of medical information

1. Step 1: Obtain the release of medical information form from the healthcare provider or facility.
2. Step 2: Fill out the patient's personal information including full name, date of birth, and address.
3. Step 3: Specify the healthcare provider/facility that will be releasing the medical information.
4. Step 4: Clearly state the purpose for releasing the medical information.
5. Step 5: Sign and date the form, and provide any necessary authorizations.
6. Step 6: Submit the completed form to the healthcare provider/facility.

Who needs release of medical information?

1. Insurance companies for processing claims.
2. Legal representatives for court cases.
3. Healthcare providers for continuity of care.
4. Individuals seeking to access their own medical records.

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What is release of medical information?

Release of medical information is a process by which a patient authorizes the disclosure of their medical records to a specified individual or organization.

Who is required to file release of medical information?

A patient or their legal representative is required to file a release of medical information in order to authorize the disclosure of their medical records.

How to fill out release of medical information?

To fill out a release of medical information, a patient typically needs to complete a form provided by their healthcare provider or facility, specifying the purpose of the disclosure and identifying the recipient of the information.

What is the purpose of release of medical information?

The purpose of release of medical information is to provide consent for healthcare providers to share a patient's medical records with specified individuals or organizations for purposes such as treatment, billing, or legal matters.

What information must be reported on release of medical information?

The information reported on a release of medical information form typically includes the patient's name, date of birth, medical record number, specific records to be disclosed, recipient of the information, purpose of disclosure, and expiration date of the authorization.