Get Medical Records Authorization Form - New Mexico Heart Institute

Completing the Medical Records Authorization Form is essential for allowing the New Mexico Heart Institute to disclose your health information. This guide will walk you through the process step-by-step, ensuring you fill out the form accurately and efficiently.

Follow the steps to complete the form correctly.

1. Press the ‘Get Form’ button to obtain the Medical Records Authorization Form and open it for editing.
2. In the designated field, enter the patient's full name. This is crucial as it identifies the individual whose health records are being authorized for disclosure.
3. Fill in the patient’s date of birth. Make sure to format the date correctly to avoid any confusion.
4. Provide the complete address, including street, city, state, and zip code. This ensures accurate identification and correspondence.
5. Enter the patient’s Social Security number, which helps in correctly associating the health records with the patient.
6. Input a contact telephone number for further communication regarding the request, if necessary.
7. Specify the individual or organization authorized to make the disclosure. Choose 'New Mexico Heart Institute' or provide another entity if needed.
8. Indicate the recipient of the disclosed information by selecting 'New Mexico Heart Institute' or identifying another individual or organization.
9. Fill in the treatment dates relevant to the request. This helps in providing context for the disclosed information.
10. Select the purpose of the request by checking all applicable options such as continuing care, insurance claim, attorney use, personal use, or other.
11. Indicate which specific information is to be disclosed by checking the 'yes' or 'no' boxes next to each item listed.
12. Review the section on sensitive information to understand what it entails and confirm your acknowledgment.
13. Understand the redisclosure implications and state your awareness of the potential risks involved.
14. Acknowledge your right to revoke this authorization by writing a statement and making sure to follow the outlined procedure.
15. Confirm that you understand signing this authorization is voluntary and does not affect your treatment.
16. Indicate an expiration date for the authorization, if desired, or recognize that it defaults to one year if left unspecified.
17. Sign the form, either as the patient or a legal representative, and provide the date of signing.
18. If applicable, specify the relationship of the legal representative to the patient when signing on their behalf.
19. Confirm whether ID verification has been completed by checking 'yes' or 'no.'
20. Finally, ensure the document is correctly verified and completed by the office staff if necessary.
21. Once all fields are filled and reviewed, users can save the changes, download, print, or share the form as needed.

Complete your Medical Records Authorization Form online today to ensure your health information is shared securely and efficiently.