Get Medical Records Release Form - John C. Lincoln Health Network

This guide provides clear and comprehensive instructions on how to fill out the Medical Records Release Form for the John C. Lincoln Health Network online. By following these steps, you can ensure that your request is completed accurately and efficiently.

Follow the steps to properly complete the online form.

1. Click ‘Get Form’ button to obtain the form and open it in your chosen editing platform.
2. In the 'Medical Records Release To' section, enter the name and address of the practice or facility that will receive your medical information.
3. Next, provide the name of the physician or facility that you authorize to disclose your health records. Fill in the respective fields including their address, city, state, zip code, phone number, and fax number.
4. Fill out your personal information in the 'Patient Identification' section. This includes your name, date of birth, address, city, state, zip code, and phone number. Ensure all information is complete to avoid delays.
5. Specify the dates of service for the medical records you are requesting. Provide the start and end dates clearly.
6. In the 'Information Requested' section, check or list the types of records you wish to obtain, such as office visit notes, laboratory results, or billing records, among others.
7. Next, in the 'Information to be Sent To' section, provide the contact details of where you want the records to be sent, if different from section two.
8. Review the authorization statement regarding the potential inclusion of sensitive information. Ensure you understand and agree to the terms before proceeding.
9. Finally, provide your signature, date, and if applicable, the signature and relationship or description of authority of a legal representative.
10. Once you have completed the form, save your changes. You can then download, print, or share the form as required.

Complete your Medical Records Release Form online today to facilitate your healthcare needs.