Get Health Records Request Form Aug28_12.pub - Occidental College - Oxy

Filling out the Health Records Request Form is a key step in authorizing the release of your medical and/or mental health information. This guide will provide clear and step-by-step instructions for completing the form online to ensure your information is shared as intended.

Follow the steps to effectively complete your health records request form.

1. Click the ‘Get Form’ button to access the Health Records Request Form. This will allow you to open the form in your preferred online editor.
2. Begin by entering your personal information in the designated fields, including your full name, date of birth, and graduation year. This ensures the right records are linked to you.
3. Input your address and phone number. This information may be used to contact you regarding your request or for follow-up if necessary.
4. Identify the individual or facility you are authorizing to release your health information. In the section labeled 'I authorize,' specify the name of the facility or person as indicated.
5. Specify the type of disclosure by checking the applicable boxes for whether you want to release or exchange your medical and/or mental health information.
6. Clearly state the purpose of the disclosure. You may choose options like 'verbal information' or 'written information,' and provide a description if required.
7. Select from the types of medical or counseling information that you wish to be released, such as copies of health records or specific immunization records. Check all that apply.
8. If there are any restrictions on the authorization, note them in the space provided to clarify any limitations on the information you would like disclosed.
9. Indicate the expiration date of the authorization. If no date is specified, it will automatically expire 12 months after the date of your signature.
10. Finally, sign and date the form in the designated areas. Ensure that you have included all necessary information to avoid delays.
11. Once completed, you can save changes, download the form, print it, or share it as needed to submit your request.

Start completing your Health Records Request Form online today to ensure your health information is managed efficiently.