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AUTHORIZATION TO RELEASE INFORMATION (Attachment A) Highpoint Health with Ascension Saint Thomas Release of Information Phone 615.328.6623 Fax 615.328.6637 or 8883301312Patients Name: ___ Patients

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How to fill out hospital medical records request

01

Obtain the hospital medical records request form, either online or at the hospital's office.

02

Fill in your personal information, including your full name, date of birth, and contact information.

03

Specify the records you are requesting, including dates of service and types of records needed (e.g., lab results, discharge summaries).

04

Provide the name of the healthcare provider or facility that may have your records, if applicable.

05

Indicate the purpose for requesting the records (e.g., personal use, transfer to another doctor).

06

Sign and date the request form to authorize the release of your medical information.

07

Submit the completed request form to the hospital's medical records department via mail, fax, or in person.

Who needs hospital medical records request?

01

Patients seeking their own medical information for personal use or to share with another healthcare provider.

02

Parents or guardians requesting medical records for their minor children.

03

Legal representatives who need medical records for legal purposes such as personal injury cases.

04

Researchers or healthcare organizations needing access to medical records for study purposes (with appropriate permissions).

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What is hospital medical records request?

A hospital medical records request is a formal application submitted to a healthcare facility to obtain a patient's medical records or health information.

Who is required to file hospital medical records request?

Patients, their legal guardians, or authorized representatives are required to file a hospital medical records request.

How to fill out hospital medical records request?

To fill out a hospital medical records request, complete the form provided by the hospital, including patient information, specific records requested, and the signature of the requesting individual.

What is the purpose of hospital medical records request?

The purpose of a hospital medical records request is to provide individuals with access to their medical history for personal use, legal matters, or continuity of care.

What information must be reported on hospital medical records request?

Required information typically includes the patient's name, date of birth, medical record number, specific dates of service, and the type of records requested.

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