Medical Records Release Form
hospital discharge papers
915 east first street duluth, mn 55805 (218) 249-2003/(218) 249-3076 (fax) first patient name: last mi date of birth medical record number i hereby authorize: to release information to: (individual name, facility/organization and address) check...
laser spine institute medical records
Patient authorization for release of medical information this form allows lsi, llc to send records on your behalf laser spine institute, llc medical records department 3031 n. rocky point drive, e., tampa, fl 33607 phone: 813-289-9613 fax:...
general medical release form
Innovative healthcare solutions. world trade center national responder health program medical records release form patient name (please print) wtc number date of birth (mm/dd/y) i authorize: name of sending person/organization: address: city,...
johns hopkins hospital medical records
For addressograph plate johns hopkins institutions johns hopkins hospital johns hopkins bayview medical center howard county general hospital authorization for release of health information not to be used in connection with health information from...
ssm medical records
Ssmhc request for access to/authorization for use and disclosure of protected health information name of ssmhc entity maintaining the information that is subject to this authorization: patient name: last first mi maiden or other name date of...
medical release form nj
Department of health and senior services consumer and environmental health services po box 369 trenton, n.j. 08625-0369 jon s. corzine governor .nj.gov/health fred m. jacobs, m.d., j.d. commissioner medical records release form patient's name:...
momdoc pay bill online
Authorization for release of medical records drs. goodman & partridge, ob/gyn attn: medical records po box 6730 chandler, az 85246 phone/fax (480) 821-3628 send records ? to drs. goodman & partridge, ob/gyn from ? from drs. goodman &partridge,...
record release form
Masshealth medical records release form commonwealth of massachusetts eohhs .mass.gov/masshealth masshealth disability evaluation service this masshealth medical records release form is to get medical information from your health-care provider so...
medical release form for criminal cases
Please place patient label here university hospital medical records one hospital drive, dc042.00 columbia, mo 65212 phone (573) 882-3170 fax (573) 882-3209 authorization for the use or disclosure of protected health information as set forth more...
pediatric medical records
Request to release medical records to: dear doctor: address: phone: fax: please release medical records for: patient name: date of birth: patient name: date of birth: patient name: date of birth: address: city: state: zip: please mail or fax...
Medical records are treated as the patient's confidential and personal information that should remain confidential. But in some situations, the clinic or hospital should provide it to third parties. Keep in mind, that this data should be disclosed only to authorized persons and organizations. Any violation of this rule can lead to the clinic being prosecuted.
There are a number of cases, when those details may be disclosed either fully or partially:
- Compensation by insurance companies.
- In the instance when the individual switches doctors or hospitals for further treatment.
- To provide evidence of physical injuries or other disabilities during court proceedings.
- To provide the results of analyses or tests needed for further employment in a company.
- Medical studies that can use particular information for making research
To complete a medical records release form, select the needed template variant from the internal form library or upload the sample used by your clinic. Add the following information:
- Patient's name, date of birth, postal address, ZIP code, city, and state.
- Contact information of the patient whose data you are providing: electronic mail address and phone number.
- The channel of sharing data with the receiver (by fax, regular mail, secure email).
- Details about the addressee (name, address, email, phone number).
- The number of records shared: all or particular.
- The certification of the person or power of attorney or health care surrogate.
- Date and printed name of a patient, certifying a document and relationship to the individual, whose notes shared (if it is applicable).
After all needed details are filled out, save the changes and send the individual or authorized person the template for certification.