Get Fax Request Form For Doctors Offices-10-2012. Fax Request Form For Doctors Offices-10-2012

Filling out the Fax Request Form For Doctors Offices-10-2012 correctly is essential for ensuring that medical records are sent promptly and accurately. This guide will provide step-by-step instructions to help you complete the form online with confidence.

Follow the steps to fill out the form accurately and efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred digital editor.
2. In the 'From (Physician Practice)' field, provide the name of the requesting physician practice, ensuring that it is clearly stated.
3. Enter the 'FAX Number' as 855-688-7649, which is the designated number for receiving the fax request.
4. Fill in the 'Mailing Address' for the recipient of the medical records to ensure they reach the correct location.
5. Complete the 'Requestor Phone Number' with a contact number where the requestor can be reached if necessary.
6. Provide the 'Date' of the request to indicate when the fax request is being sent.
7. Enter the 'Requestor Fax Number' for communication purposes should there be any issues.
8. Specify the 'Date needed by requestor' to inform the provider of the urgency of the request.
9. Fill in the 'Patient Name' fields with the last name, first name, and middle initial of the patient for whom the records are requested.
10. Enter the 'DOB' (date of birth) of the patient. This helps in confirming the identity of the individual.
11. Input the 'Last 4 of SS#' (Social Security Number) to further verify patient identity.
12. In the 'Reason for Request' section, select the appropriate reason by checking the relevant box, such as 'Patient currently in the office – STAT' or 'Patient has an appointment on'.
13. Provide the 'Office Fax number' where the records should be sent. Specify if records are to be mailed for billing purposes.
14. Select the facility from the provided options and include the 'date of service' related to the medical records being requested.
15. Choose the 'Type of Records Requested' by checking the boxes for the relevant documents needed.
16. Review each section of the form to ensure all fields are completed accurately before submitting.
17. Once the form is complete, save changes, and if necessary, download, print, or share the completed form as required.

Complete your Fax Request Form For Doctors Offices-10-2012 online to ensure timely access to medical records.