Get Medical Records Release Form - Lake Pointe Medical Center

Filling out the Medical Records Release Form is an important process to authorize the use and disclosure of your health information. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the Medical Records Release Form

1. Click ‘Get Form’ button to access the Medical Records Release Form and open it for editing.
2. In Section A, enter the patient’s name, home address, home telephone number, alternate phone number, and date of birth. Ensure all details are correct for proper identification.
3. In Section B, specify the information you wish to disclose. Clearly indicate what records or details you want to include in this release.
4. In Section C, review the list of highly confidential information. Check the appropriate boxes to indicate if any of the categories apply, understanding that you are granting permission for their disclosure.
5. In Section D, determine the duration of the authorization. Select whether it will remain effective until a specific event occurs, a designated time, or until the center fulfills the request.
6. In Section E, state the purpose of your authorization. You may simply write 'At the request of the patient' if applicable.
7. Review the information in Section F carefully. Acknowledge your understanding about the limits of confidentiality once the information is disclosed. Confirm that you can revoke this authorization at any time.
8. At the bottom of the form, sign where indicated as the patient or as the authorized personal representative. Include the date of signing.
9. Make sure to save your completed form. After saving, you can download, print, or share the Medical Records Release Form as needed.

Complete your document online now to ensure your health information is managed efficiently.