Get 855 519 9682

This guide provides clear instructions on how to fill out the 855 519 9682 form online, ensuring that your submission is complete and accurate. Follow these steps to successfully navigate the form and submit your request for the release of protected health information.

Follow the steps to complete your form accurately.

1. Click ‘Get Form’ button to access the form and open it in your preferred viewer.
2. Fill in the shaded areas of the form completely. Start with the patient’s name, birth date, and contact number. Include the social security number if comfortable.
3. Provide the recipient's details, including their name, phone number, fax number, and address.
4. Clearly state the purpose(s) of the release of protected health information. Options may include marketing, research, or other specified reasons.
5. Indicate the type of access requested by checking one of the options: Copies of record, inspection of records, or release to media/marketing.
6. Select the specific medical records you are requesting. You can choose from options such as entire medical record, physician orders, progress notes, or clinical tests. Specify dates if necessary.
7. Authorize the release by checking the hospital or medical center from which you are requesting the information.
8. Sign and date the form, ensuring that the signature matches the name printed on the form. If applicable, include the relationship to the patient.
9. Verify identification by selecting the type of ID used. Ensure to include a copy of the valid photo ID with your submission.
10. Once completed, you may save the changes, download the form, print it, or share it as needed.

Complete your documents online for a smoother experience and quicker processing.