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AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION (PHI)RECORD RELEASE REQUESTPart 1: AuthorizationName: Date of Birth: Address: Phone Number: By signing this Authorization, I hereby authorize Plymouth Pediatric Associates (PPA) to release my protected health information (PHI) as indicated below to the person(s)/agency(s)/facility(s) named in Part 2 of the form (each a Recipient).Part
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How to fill out medical-record-releaseppadocx template

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How to fill out medical-record-releaseppadocx

01
Obtain the medical record release form, typically provided by the healthcare provider.
02
Fill out your personal information, including full name, date of birth, and contact information.
03
Indicate the specific medical records you wish to release, such as dates of service or types of records.
04
Provide the name and address of the recipient who will receive your medical records.
05
Sign and date the form to authorize the release of your medical records.
06
Submit the completed form to your healthcare provider's office as instructed.

Who needs medical-record-releaseppadocx?

01
Patients seeking to share their medical records with another healthcare provider.
02
Individuals applying for insurance coverage requiring previous medical history.
03
Legal representatives or guardians needing access to a patient's medical records.
04
Patients transferring care to a new physician or specialist.

What is Medical-Record-ReleasePPA.docx Form?

The Medical-Record-ReleasePPA.docx is a fillable form in MS Word extension you can get filled-out and signed for specific purpose. Then, it is furnished to the exact addressee in order to provide some information and data. The completion and signing may be done manually in hard copy or using a trusted solution like PDFfiller. Such services help to submit any PDF or Word file without printing them out. It also allows you to edit its appearance for your needs and put a legal e-signature. Once finished, the user ought to send the Medical-Record-ReleasePPA.docx to the respective recipient or several of them by email or fax. PDFfiller is known for a feature and options that make your document of MS Word extension printable. It includes a number of settings for printing out. It doesn't matter how you will send a form after filling it out - physically or by email - it will always look neat and firm. In order not to create a new document from the beginning all the time, turn the original Word file as a template. Later, you will have a rewritable sample.

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Medical-record-releaseppadocx is a document used to authorize the release of a patient's medical records from healthcare providers, permitting information to be shared with designated individuals or entities.
The document must be filed by patients or their authorized representatives who wish to obtain or share their medical records.
To fill out medical-record-releaseppadocx, you need to provide the patient's personal information, specify the records to be released, designate who will receive the records, and sign the document to authorize the release.
The purpose of medical-record-releaseppadocx is to ensure that patients have control over their medical information and can authorize its release for various purposes, such as continuity of care, legal matters, or insurance claims.
The information that must be reported includes the patient's full name, date of birth, details of the medical records to be released, the recipient of the records, the purpose of the release, and the patient's signature.
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